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Arconada Alvarez SJ, Hoover AT, Greenleaf M, Ray SM, Schechter MC, Blumberg HM, Lam WA. "An app is just available at all times"-the process and outcomes of converting the Georgia Tuberculosis Reference Guide into a mobile application. PLoS One 2024; 19:e0298758. [PMID: 38753810 PMCID: PMC11098468 DOI: 10.1371/journal.pone.0298758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/31/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND The physical, paper-based Georgia TB Reference Guide has served as the clinical reference handbook on tuberculosis (TB) diagnostic and treatment guidelines for the state of Georgia in the United States. Supported by the Georgia Department of Public Health, the production of the 112-page palm-sized booklet was previously led by a team of Georgia-based TB experts at Emory University and printed every three-five years with updates to clinical management guidelines and TB consult contact information. However, the costs associated with editorial printing combined with delays in updating a static printed booklet with revised guidance hampered the utility of the tool. Considering the barriers with paper-based production and based on the beneficial use of apps to support the dissemination of clinical management guidance in other settings, the booklet was converted into a mobile application. This paper describes the process of developing a mobile app version of the Georgia TB Reference Guide in an easy-to-update and readily available format. METHODS We employed a user-centered design approach to develop the app, including a series of qualitative interviews and quantitative surveys. Participants included a mix of state officials and local TB experts. First, initial foundational interviews were conducted to conceptualize current utilization practices of both the paper and PDF versions of the tool. Second, the findings from the initial interviews were organized thematically and informed the design of the app, which was then beta tested by a round of previously unsampled TB experts as well as a re-sample from the initial interviews. Third, the designs were coded into developmental phases and beta tested among users of the current Georgia TB Reference Guide. Fourth, the app was published and downloaded by a pre-selected group of local users who provided answers to a follow-up survey after using the app for one month. Fifth, user growth, self-reported demographics, and app usage between February and July 2022 were recorded through automatic data metrics built into the app. RESULTS The paper copy Georgia TB Reference Guide usage themes included commonly referenced content, navigation paths, and desired features and content. The themes were converted into features and designs such as prioritizing commonly reviewed topics and guide customization with bookmarks and notes. Iterations of the designs were driven by feedback from TB experts and included home page featured content, improving content readability, and improving the search feature. The follow-up survey revealed a 90% preference for the app over the paper version of the guide. In the six months following the app's release, the app was downloaded by 281 individuals in the United States. The majority of downloads were in Georgia and the app also expanded organically to 19 other states. CONCLUSION The experience of converting the Georgia TB Reference Guide offers specific and effective steps to converting a medical reference guide into a mobile application tool that is readily available, easy to use, and easy to update. The organic dissemination of the app beyond the state of Georgia's borders within the first six months of app launch underscores desire among TB healthcare professionals for high-quality digital reference content outside the state. This experience offers clear outlines for replication in other contexts and demonstrates the utility of similar mobile medical reference tools.
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Affiliation(s)
- Santiago J. Arconada Alvarez
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- AppHatchery, Georgia Clinical and Translational Science Alliance, Atlanta, Georgia, United States of America
| | - Alison T. Hoover
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Morgan Greenleaf
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- AppHatchery, Georgia Clinical and Translational Science Alliance, Atlanta, Georgia, United States of America
| | - Susan M. Ray
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Grady Memorial Hospital, Atlanta, Georgia, United States of America
- Georgia Department of Public Health Tuberculosis Program, Atlanta, Georgia, United States of America
| | - Marcos C. Schechter
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Grady Memorial Hospital, Atlanta, Georgia, United States of America
- Georgia Department of Public Health Tuberculosis Program, Atlanta, Georgia, United States of America
| | - Henry M. Blumberg
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Grady Memorial Hospital, Atlanta, Georgia, United States of America
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Wilbur A. Lam
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- AppHatchery, Georgia Clinical and Translational Science Alliance, Atlanta, Georgia, United States of America
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, United States of America
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States of America
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Edwards SJ, Yao J, Schechter MC, Fayfman M, Santamarina G, Feiweier T, Blanco G, Alvarez J, Risk BB, Rajani R, Reiter DA. Feasibility of Multiparametric Perfusion Assessment in Diabetic Foot Ulcer Using Intravoxel Incoherent Motion and Blood Oxygenation-Level Dependent MRI. J Magn Reson Imaging 2024; 59:1555-1566. [PMID: 37596872 PMCID: PMC10875144 DOI: 10.1002/jmri.28955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Patients with type-2 diabetes (T2DM) are at increased risk of developing diabetic foot ulcers (DFU) and experiencing impaired wound healing related to underlying microvascular disease. PURPOSE To evaluate the sensitivity of intra-voxel incoherent motion (IVIM) and blood oxygen level dependent (BOLD) MRI to microvascular changes in patients with DFUs. STUDY TYPE Case-control. POPULATION 20 volunteers who were age and body mass index matched, including T2DM patients with DFUs (N = 10, mean age = 57.5 years), T2DM patients with controlled glycemia and without DFUs (DC, N = 5, mean age = 57.4 years) and healthy controls (HC, N = 5, mean age = 52.8 years). FIELD STRENGTH/SEQUENCE 3T/multi-b-value IVIM and dynamic BOLD. ASSESSMENT Resting IVIM parameters were obtained using a multi-b-value diffusion-weighted imaging sequence and two IVIM models were fit to obtain diffusion coefficient (D), pseudo-diffusion coefficient (D*), perfusion fraction (f) and microvascular volume fraction (MVF) parameters. Microvascular reactivity was evaluated by inducing an ischemic state in the foot with a blood pressure cuff during dynamic BOLD imaging. Perfusion indices were assessed in two regions of the foot: the medial plantar (MP) and lateral plantar (LP) regions. STATISTICAL TESTS Effect sizes of group mean differences were assessed using Hedge's g adjusted for small sample sizes. RESULTS DFU participants exhibited elevated D*, f, and MVF values in both regions (g ≥ 1.10) and increased D (g = 1.07) in the MP region compared to DC participants. DC participants showed reduced f and MVF compared to HC participants in the MP region (g ≥ 1.06). Finally, the DFU group showed reduced tolerance for ischemia in the LP region (g = -1.51) and blunted reperfusion response in both regions (g < -2.32) compared to the DC group during the cuff-occlusion challenge. DATA CONCLUSION The combined use of IVIM and BOLD MRI shows promise in differentiating perfusion abnormalities in the feet of diabetic patients and suggests hyperperfusion in DFU patients. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
- Scott J. Edwards
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Jingting Yao
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Marcos C. Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Maya Fayfman
- Grady Memorial Hospital, Atlanta, Georgia, USA
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Gabriel Santamarina
- Grady Memorial Hospital, Atlanta, Georgia, USA
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Division of Vascular Surgery, Department of Surgery, Atlanta, GA, United States of America
| | | | - Gerardo Blanco
- Grady Memorial Hospital, Atlanta, Georgia, USA
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jessica Alvarez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Benjamin B. Risk
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Ravi Rajani
- Grady Memorial Hospital, Atlanta, Georgia, USA
- Division of Vascular Surgery, Department of Surgery, Atlanta, GA, United States of America
| | - David A. Reiter
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Orthopedics, Emory University School of Medicine, Atlanta, Georgia, USA
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Mikiashvili L, Kempker RR, Chakhaia TS, Bablishvili N, Avaliani Z, Lomtadze N, Schechter MC, Kipiani M. Impact of Prior Tuberculosis Treatment With New/Companion Drugs on Clinical Outcomes in Patients Receiving Concomitant Bedaquiline and Delamanid for Multidrug- and Rifampicin-Resistant Tuberculosis. Clin Infect Dis 2024; 78:1043-1052. [PMID: 37962987 PMCID: PMC11006115 DOI: 10.1093/cid/ciad694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND There are scarce data on the clinical outcomes of persons retreated with new/companion anti-tuberculosis (TB) drugs for multidrug- and rifampicin-resistant tuberculosis (MDR/RR-TB). We sought to evaluate the efficacy and safety of bedaquiline and delamanid containing regimens among patients with and without prior exposure to the new/companion drugs (bedaquiline, delamanid, linezolid, clofazimine, and fluoroquinolones). METHODS We conducted a retrospective cohort study among patients with pulmonary MDR/RR-TB in Georgia who received bedaquiline and delamanid combination as a part of a salvage regimen from November 2017 to December 2020 in a programmatic setting. RESULTS Among 106 persons with a median age of 39.5 years, 44 (41.5%) were previously treated with new/companion TB drugs. Patients with prior exposure to new/companion drugs had higher rates of baseline resistance compared to those without exposure to new/companion TB drugs (bedaquiline 15.2% vs 1.8%, linezolid 22.2% vs 16.7%). Sputum culture conversion rates among patients exposed and not exposed to new/companion drugs were 65.9% vs 98.0%, respectively (P < .001). Among patients with and without prior new/companion TB drug use, favorable outcome rates were 41.0% and 82.3%, respectively (P < .001). Treatment adherence in 32 (30.2%) patients was ≤80%. Five of 21 patients (23.8%) who had a baseline and repeat susceptibility test had acquired bedaquiline resistance. QTC/F prolongation (>500 ms) was rare (2.8%). CONCLUSIONS Prior exposure to new/companion TB drugs was associated with poor clinical outcomes and acquired drug resistance. Tailoring the TB regimen to each patient's drug susceptibility test results and burden of disease and enhancing adherence support may improve outcomes.
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Affiliation(s)
- L Mikiashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - R R Kempker
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - T S Chakhaia
- School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - N Bablishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - N Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- Department of Medicine, David Tvildiani Medical University, Tbilisi, Georgia
- Department of Medicine, The University of Georgia, Tbilisi, Georgia
| | - M C Schechter
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - M Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- Department of Medicine, David Tvildiani Medical University, Tbilisi, Georgia
- Department of Medicine, The University of Georgia, Tbilisi, Georgia
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Baseman C, Fayfman M, Schechter MC, Ostadabbas S, Santamarina G, Ploetz T, Arriaga RI. Intelligent Care Management for Diabetic Foot Ulcers: A Scoping Review of Computer Vision and Machine Learning Techniques and Applications. J Diabetes Sci Technol 2023:19322968231213378. [PMID: 37953531 DOI: 10.1177/19322968231213378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Ten percent of adults in the United States have a diagnosis of diabetes and up to a third of these individuals will develop a diabetic foot ulcer (DFU) in their lifetime. Of those who develop a DFU, a fifth will ultimately require amputation with a mortality rate of up to 70% within five years. The human suffering, economic burden, and disproportionate impact of diabetes on communities of color has led to increasing interest in the use of computer vision (CV) and machine learning (ML) techniques to aid the detection, characterization, monitoring, and even prediction of DFUs. Remote monitoring and automated classification are expected to revolutionize wound care by allowing patients to self-monitor their wound pathology, assist in the remote triaging of patients by clinicians, and allow for more immediate interventions when necessary. This scoping review provides an overview of applicable CV and ML techniques. This includes automated CV methods developed for remote assessment of wound photographs, as well as predictive ML algorithms that leverage heterogeneous data streams. We discuss the benefits of such applications and the role they may play in diabetic foot care moving forward. We highlight both the need for, and possibilities of, computational sensing systems to improve diabetic foot care and bring greater knowledge to patients in need.
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Affiliation(s)
- Cynthia Baseman
- School of Interactive Computing, Georgia Institute of Technology, Atlanta, GA, USA
| | - Maya Fayfman
- Grady Health System, Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Marcos C Schechter
- Grady Health System, Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Sarah Ostadabbas
- Department of Electrical & Computer Engineering, Northeastern University, Boston, MA, USA
| | - Gabriel Santamarina
- Department of Medicine and Orthopaedics, School of Medicine, Emory University, Atlanta, GA, USA
| | - Thomas Ploetz
- School of Interactive Computing, Georgia Institute of Technology, Atlanta, GA, USA
| | - Rosa I Arriaga
- School of Interactive Computing, Georgia Institute of Technology, Atlanta, GA, USA
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Haley CA, Schechter MC, Ashkin D, Peloquin CA, Peter Cegielski J, Andrino BB, Burgos M, Caloia LA, Chen L, Colon-Semidey A, DeSilva MB, Dhanireddy S, Dorman SE, Dworkin FF, Hammond-Epstein H, Easton AV, Gaensbauer JT, Ghassemieh B, Gomez ME, Horne D, Jasuja S, Jones BA, Kaplan LJ, Khan AE, Kracen E, Labuda S, Landers KM, Lardizabal AA, Lasley MT, Letzer DM, Lopes VK, Lubelchek RJ, Patricia Macias C, Mihalyov A, Misch EA, Murray JA, Narita M, Nilsen DM, Ninneman MJ, Ogawa L, Oladele A, Overman M, Ray SM, Ritger KA, Rowlinson MC, Sabuwala N, Schiller TM, Schwartz LE, Spitters C, Thomson DB, Tresgallo RR, Valois P, Goswami ND. Implementation of Bedaquiline, Pretomanid, and Linezolid in the United States: Experience Using a Novel All-Oral Treatment Regimen for Treatment of Rifampin-Resistant or Rifampin-Intolerant Tuberculosis Disease. Clin Infect Dis 2023; 77:1053-1062. [PMID: 37249079 PMCID: PMC11001496 DOI: 10.1093/cid/ciad312] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/20/2023] [Accepted: 05/27/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Rifampin-resistant tuberculosis is a leading cause of morbidity worldwide; only one-third of persons start treatment, and outcomes are often inadequate. Several trials demonstrate 90% efficacy using an all-oral, 6-month regimen of bedaquiline, pretomanid, and linezolid (BPaL), but significant toxicity occurred using 1200-mg linezolid. After US Food and Drug Administration approval in 2019, some US clinicians rapidly implemented BPaL using an initial 600-mg linezolid dose adjusted by serum drug concentrations and clinical monitoring. METHODS Data from US patients treated with BPaL between 14 October 2019 and 30 April 2022 were compiled and analyzed by the BPaL Implementation Group (BIG), including baseline examination and laboratory, electrocardiographic, and clinical monitoring throughout treatment and follow-up. Linezolid dosing and clinical management was provider driven, and most patients had linezolid adjusted by therapeutic drug monitoring. RESULTS Of 70 patients starting BPaL, 2 changed to rifampin-based therapy, 68 (97.1%) completed BPaL, and 2 of the 68 (2.9%) experienced relapse after completion. Using an initial 600-mg linezolid dose daily adjusted by therapeutic drug monitoring and careful clinical and laboratory monitoring for adverse effects, supportive care, and expert consultation throughout BPaL treatment, 3 patients (4.4%) with hematologic toxicity and 4 (5.9%) with neurotoxicity required a change in linezolid dose or frequency. The median BPaL duration was 6 months. CONCLUSIONS BPaL has transformed treatment for rifampin-resistant or intolerant tuberculosis. In this cohort, effective treatment required less than half the duration recommended in 2019 US guidelines for drug-resistant tuberculosis. Use of individualized linezolid dosing and monitoring likely enhanced safety and treatment completion. The BIG cohort demonstrates that early implementation of new tuberculosis treatments in the United States is feasible.
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Affiliation(s)
- Connie A Haley
- Southeastern National Tuberculosis Center, Division of Infectious Diseases and Global Medicine, Department of Medicine in the College of Medicine, University of Florida, Gainesville, Florida, USA
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marcos C Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Georgia State Tuberculosis Program, Atlanta, Georgia, USA
| | - David Ashkin
- Southeastern National Tuberculosis Center, Division of Infectious Diseases and Global Medicine, Department of Medicine in the College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Charles A Peloquin
- Translational Research, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - J Peter Cegielski
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Marcos Burgos
- New Mexico Department of Health, Santa Fe, New Mexico, USA
- University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- New Mexico Veterans Affairs Health Care System, Albuquerque, New Mexico, USA
| | - Lori A Caloia
- Louisville Metro Department of Public Health and Wellness, Louisville, Kentucky, USA
- Humana Healthy Horizons in Kentucky, Louisville, Kentucky, USA
| | - Lisa Chen
- Curry International Tuberculosis Center, University of California, San Francisco, California, USA
| | | | - Malini B DeSilva
- Saint Paul–Ramsey County Public Health, Saint Paul, Minnesota, USA
- HealthPartners Institute, Bloomington, Minnesota, USA
| | - Shireesha Dhanireddy
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Susan E Dorman
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
- South Carolina Department of Health and Environmental Control, Greenville, South Carolina, USA
| | - Felicia F Dworkin
- New York City Department of Health and Mental Hygiene, Bureau of Tuberculosis Control, New York, New York, USA
| | - Heidi Hammond-Epstein
- Southeastern National Tuberculosis Center, University of Florida, Gainesville, Florida, USA
| | - Alice V Easton
- New York City Department of Health and Mental Hygiene, Bureau of Tuberculosis Control, New York, New York, USA
| | - James T Gaensbauer
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bijan Ghassemieh
- Public Health—Seattle & King County, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Maria E Gomez
- Southeastern National Tuberculosis Center, University of Florida, Gainesville, Florida, USA
| | - David Horne
- Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Supriya Jasuja
- Cook County Department of Public Health, Forest Park, Illinois, USA
| | - Betsy A Jones
- Bureau of Public Health Laboratories, Florida State Tuberculosis Program, Jacksonville, Florida, USA
| | - Leonard J Kaplan
- Division of Infectious Diseases, Department of Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | | | - Elizabeth Kracen
- Public Health—Seattle & King County, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Sarah Labuda
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Puerto Rico Department of Health, San Juan, Puerto Rico, USA
| | - Karen M Landers
- Alabama Department of Public Health, Montgomery, Alabama, USA
| | | | - Maria T Lasley
- Southeastern National Tuberculosis Center, University of Florida, Gainesville, Florida, USA
| | | | - Vinicius K Lopes
- Sheboygan County Health and Human Services, Sheboygan, Wisconsin, USA
- Southern California Infectious Diseases Associates, Inc., Newport Beach, California, USA
| | - Ronald J Lubelchek
- Cook County Department of Public Health, Forest Park, Illinois, USA
- Division of Infectious Diseases, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
- Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - C Patricia Macias
- Health Transformation Program NorthShore University, Chicago, Illinois, USA
- The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Aimee Mihalyov
- Louisville Metro Department of Public Health and Wellness, Louisville, Kentucky, USA
| | - Elizabeth Ann Misch
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jason A Murray
- Emergency Medicine, Saint Elizabeth Healthcare System, Edgewood, Kentucky, USA
- Northern Kentucky Health Department, Florence, Kentucky, USA
| | - Masahiro Narita
- Public Health—Seattle & King County, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Diana M Nilsen
- New York City Department of Health and Mental Hygiene, Bureau of Tuberculosis Control, New York, New York, USA
| | | | - Lynne Ogawa
- Saint Paul–Ramsey County Public Health, Saint Paul, Minnesota, USA
| | | | - Melissa Overman
- South Carolina Department of Health and Environmental Control, Greenville, South Carolina, USA
| | - Susan M Ray
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Georgia State Tuberculosis Program, Atlanta, Georgia, USA
| | | | - Marie-Claire Rowlinson
- Bureau of Public Health Laboratories, Florida State Tuberculosis Program, Jacksonville, Florida, USA
- Wadsworth Center, New York State Department of Health, Albany, New York, USA
| | - Nadya Sabuwala
- Minnesota Department of Health, Saint Paul, Minnesota, USA
| | | | | | - Christopher Spitters
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Snohomish County Health Department, Everett, Washington, USA
- Washington State Department of Health, Shoreline, Washington, USA
| | - Douglas B Thomson
- Barren River District Health Department, Bowling Green, Kentucky, USA
| | - Rene Rico Tresgallo
- Department of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Florida, USA
| | - Patrick Valois
- Bureau of Public Health Laboratories, Florida State Tuberculosis Program, Jacksonville, Florida, USA
| | - Neela D Goswami
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Cortes-Penfield NW, Armstrong DG, Brennan MB, Fayfman M, Ryder JH, Tan TW, Schechter MC. Executive Summary: Evaluation and Management of Diabetes-related Foot Infections. Clin Infect Dis 2023; 77:335-337. [PMID: 37579721 PMCID: PMC10681639 DOI: 10.1093/cid/ciad429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 08/16/2023] Open
Affiliation(s)
| | - David G Armstrong
- Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Meghan B Brennan
- Division of Infectious Diseases, University of Wisconsin-Madison Medical Center, Madison, Wisconsin, USA
| | - Maya Fayfman
- Division of Endocrinology & Metabolism, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Jonathan H Ryder
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Tze-Woei Tan
- Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Marcos C Schechter
- Department of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
- Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
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Cortes-Penfield NW, Armstrong DG, Brennan MB, Fayfman M, Ryder JH, Tan TW, Schechter MC. Evaluation and Management of Diabetes-related Foot Infections. Clin Infect Dis 2023; 77:e1-e13. [PMID: 37306693 PMCID: PMC10425200 DOI: 10.1093/cid/ciad255] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Indexed: 06/13/2023] Open
Affiliation(s)
| | - David G Armstrong
- Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Meghan B Brennan
- Division of Infectious Diseases, University of Wisconsin, Madison, Wisconsin, USA
| | - Maya Fayfman
- Division of Endocrinology and Metabolism, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Jonathan H Ryder
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Tze-Woei Tan
- Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Marcos C Schechter
- Department of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
- Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
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Houck K, Chakhaia T, Gorvetzian S, Critchley JA, Schechter MC, Magee MJ. Diabetes Mellitus and Tuberculosis Treatment Outcomes: Interaction Assessment Between Hyperglycemia and Human Immunodeficiency Virus in the State of Georgia, 2015-2020. Open Forum Infect Dis 2023; 10:ofad255. [PMID: 37383249 PMCID: PMC10295156 DOI: 10.1093/ofid/ofad255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/09/2023] [Indexed: 06/30/2023] Open
Abstract
Background Diabetes mellitus and human immunodeficiency virus (HIV) are independent risk factors for poor outcomes among people with tuberculosis (TB). To date, information on the joint impact of diabetes and HIV on TB outcomes is limited. We aimed to estimate (1) the association between hyperglycemia and mortality and (2) the effect of joint exposure to diabetes and HIV on mortality. Methods We conducted a retrospective cohort study among people with TB in the state of Georgia between 2015 and 2020. Eligible participants were 16 or older, did not have a previous TB diagnosis, and were microbiologically confirmed or clinical cases. Participants were followed during TB treatment. Robust Poisson regression was used to estimate risk ratios for all-cause mortality. Interaction between diabetes and HIV was assessed on the additive scale using the attributable proportion and on the multiplicative scale with product terms in regression models. Results Of 1109 participants, 318 (28.7%) had diabetes, 92 (8.3%) were HIV positive, and 15 (1.4%) had diabetes and HIV. Overall, 9.8% died during TB treatment. Diabetes was associated with an increased risk of death among people with TB (adjusted risk ratio [aRR] = 2.59; 95% confidence interval [CI], 1.62-4.13). We estimated that 26% (95% CI, -43.4% to 95.0%) of deaths among participants with diabetes mellitus and HIV were due to biologic interaction. Conclusions Diabetes alone and co-occurring diabetes and HIV were associated with an increased risk of all-cause mortality during TB treatment. These data suggest a potential synergistic effect between diabetes and HIV.
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Affiliation(s)
- Kennedy Houck
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Tsira Chakhaia
- Department of Population Health Sciences, Georgia State University, Atlanta, Georgia, USA
| | - Sarah Gorvetzian
- Division of Infectious Diseases, Department of Medicine, Emory School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Julia A Critchley
- Population Health Research Institute, St. George's, University of London, London, United Kingdom
| | - Marcos C Schechter
- Division of Infectious Diseases, Department of Medicine, Emory School of Medicine, Emory University, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
- Georgia Department of Public Health Tuberculosis Program, Atlanta, Georgia, USA
| | - Matthew J Magee
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Division of Infectious Diseases, Department of Medicine, Emory School of Medicine, Emory University, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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9
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Brennan MB, Tan TW, Schechter MC, Fayfman M. Using the National Institute on Minority Health and Health Disparities framework to better understand disparities in major amputations. Semin Vasc Surg 2023; 36:19-32. [PMID: 36958894 PMCID: PMC10039286 DOI: 10.1053/j.semvascsurg.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023]
Abstract
Recently, the United States experienced its first resurgence of major amputations in more than 20 years. Compounding this rise is a longstanding history of disparities. Patients identifying as non-Hispanic Black are twice as likely to lose a limb as those identifying as non-Hispanic White. Those identifying as Latino face a 30% increase. Rural patients are also more likely to undergo major amputations, and the rural-urban disparity is widening. We used the National Institute on Minority Health and Health Disparities framework to better understand these disparities and identify common factors contributing to them. Common factors were abundant and included increased prevalence of diabetes, possible lower rates of foot self-care, transportation barriers to medical appointments, living in disadvantaged neighborhoods, and lack of insurance. Solutions within and outside the health care realm are needed. Health care-specific interventions that embed preventative and ambulatory care services within communities may be particularly high yield.
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Affiliation(s)
- Meghan B Brennan
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, Madison, WI, 53583.
| | - Tze-Woei Tan
- Department of Surgery, Keck School of Medicine University of Southern California, Los Angeles, CA
| | - Marcos C Schechter
- Department of Medicine, Emory University School of Medicine, Atlanta, GA; Grady Health System, Atlanta, GA
| | - Maya Fayfman
- Department of Medicine, Emory University School of Medicine, Atlanta, GA; Grady Health System, Atlanta, GA
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10
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Schechter MC, Yao Y, Patel M, Andruski R, Rab S, Wong JR, Santamarina G, Fayfman M, Rajani R, Kempker RR. Outpatient Parenteral Antibiotic Therapy for Diabetic Foot Osteomyelitis in an Uninsured and Underinsured Cohort. Infect Dis Clin Pract (Baltim Md) 2023; 31:e1219. [PMID: 37520685 PMCID: PMC10373103 DOI: 10.1097/ipc.0000000000001219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Background Diabetic foot osteomyelitis (DFO) is usually treated with prolonged outpatient parenteral antibiotic therapy (OPAT). Evaluation and treatment of non-antibiotic aspects of DFO (e.g., peripheral artery disease [PAD]) are also recommended. There is limited data regarding OPAT practice patterns and outcomes for DFO. Methods Single-center observational study of patients receiving OPAT for DFO in a large United States public hospital between January 2017 and July 2019. We abstracted data regarding microbiology test, antibiotics, clinical outcomes, and non-antibiotic DFO management. Results Ninety-six patients were included and some had >1 DFO-OPAT course during the study period (106 DFO-OPAT courses included). No culture was obtained in 40 (38%) of courses. Methicillin-resistant S. aureus (MRSA) was cultured in 15 (14%) and P. aeruginosa in 1 (1%) of DFO-OPAT courses. An antibiotic with MRSA activity (vancomycin or daptomycin) was used in 79 (75%) of courses and a parenteral antibiotic with anti-pseudomonal activity was used in 7 (6%) of courses. Acute kidney injury occurred in 19 (18%) DFO-OPAT courses. An ankle-brachial index measurement was obtained during or 6 months prior to the first DFO-OPAT course for 44 (49%) of patients. Forty-two (44%) patients died or had an amputation within 12 months of their initial hospital discharge. Conclusions We found high rates of empiric antibiotic therapy for DFO and low uptake of the non-antibiotic aspects of DFO care. Better implementation of microbiological tests for DFO in addition to stronger integration of infectious disease and non-infectious diseases care could improve DFO outcomes.
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Affiliation(s)
- Marcos C. Schechter
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
- Grady Health System, Atlanta, GA
| | - Yutong Yao
- Rollings School of Public Health, Emory University, Atlanta, Georgia
| | | | | | | | | | - Gabriel Santamarina
- Grady Health System, Atlanta, GA
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Maya Fayfman
- Grady Health System, Atlanta, GA
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Ravi Rajani
- Grady Health System, Atlanta, GA
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Russell R. Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
- Grady Health System, Atlanta, GA
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11
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Satola SW, Schechter MC, Wilde S, Stephens DS. Host Defenses to Extracellular Bacteria Including Spirochetes. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00027-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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Abstract
Best Oral Therapy for Staph aureus OsteomyelitisA 50-year-old patient with diabetes mellitus has a plantar ulcer at the base of the first metatarsal. Cortical erosions are noted; bone biopsy culture yields Staphylococcus aureus susceptible to methicillin, ciprofloxacin, clindamycin, doxycycline, trimethoprim/sulfamethoxazole, linezolid, and rifampin. The plan is for 4 weeks of antibiotic treatment. Which antibiotic should be prescribed?
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Affiliation(s)
- Marcos C Schechter
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta
- Grady Memorial Hospital, Atlanta
| | - Paul E Sax
- Division of Infectious Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston
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13
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Mahgoub U, Magee MJ, Heydari M, Choudhary M, Santamarina G, Schenker M, Rajani R, Umpierrez GE, Fayfman M, Chang HH, Schechter MC. Outpatient clinic attendance and outcomes among patients hospitalized with diabetic foot ulcers. J Diabetes Complications 2022; 36:108283. [PMID: 36063661 PMCID: PMC10278062 DOI: 10.1016/j.jdiacomp.2022.108283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND There are limited data on post-hospital discharge clinic attendance rates and outcomes among patients with diabetic foot ulcers (DFUs). METHODS Retrospective study of patients hospitalized with a DFU from 2016 to 2019 in a large public hospital. We measured rates and predictors of clinic attendance with providers involved with DFU care within 30 days of hospital discharge ("30-day post-discharge clinic attendance"). Log-binomial regression was used to estimate risk ratios (RR) and 95 % confidence intervals (CI). RESULTS Among 888 patients, 60.0 % were between 45 and 64 years old, 80.5 % were Black, and 24.1 % were uninsured. Overall, 478 (53.8 %) attended ≥1 30-day post-discharge clinic appointment. Initial hospital outcomes were associated with clinic attendance. For example, the RR of 30-day post-discharge clinic attendance was 1.39 (95%CI 1.19-1.61) among patients who underwent a major amputation compared to patients with DFUs without osteomyelitis and did not undergo an amputation during the initial hospitalization. Among 390 patients with known 12-month outcome, 71 (18.2 %) had a major amputation or died ≤12 months of hospital discharge. CONCLUSION We found a low post-discharge clinic attendance and high post-discharge amputation and death rates among patients hospitalized with DFUs. Interventions to increase access to outpatient DFU care are needed and could prevent amputations.
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Affiliation(s)
- Umnia Mahgoub
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, GA, United States of America
| | - Matthew J Magee
- Rollins School of Public Heath, Department of Global Health, Emory University, Atlanta, GA, United States of America
| | - Maryam Heydari
- Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, GA, United States of America
| | - Muaaz Choudhary
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States of America
| | - Gabriel Santamarina
- Grady Memorial Hospital, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Endocrinology Metabolism and Lipids, Department of Medicine, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Vascular Surgery, Department of Surgery, Atlanta, GA, United States of America
| | - Mara Schenker
- Emory University School of Medicine, Division of Vascular Surgery, Department of Surgery, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Orthopedic Surgery, Department of Surgery, Atlanta, GA, United States of America
| | - Ravi Rajani
- Grady Memorial Hospital, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Vascular Surgery, Department of Surgery, Atlanta, GA, United States of America
| | - Guillermo E Umpierrez
- Grady Memorial Hospital, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Endocrinology Metabolism and Lipids, Department of Medicine, Atlanta, GA, United States of America
| | - Maya Fayfman
- Grady Memorial Hospital, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Endocrinology Metabolism and Lipids, Department of Medicine, Atlanta, GA, United States of America
| | - Howard H Chang
- Rollins School of Public Heath, Department of Global Health, Emory University, Atlanta, GA, United States of America
| | - Marcos C Schechter
- Emory University School of Medicine, Division of Endocrinology Metabolism and Lipids, Department of Medicine, Atlanta, GA, United States of America; Emory University School of Medicine, Division of Infectious Diseases, Department of Medicine, Atlanta, GA, United States of America.
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14
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Georghiou SB, Rodwell TC, Korobitsyn A, Abbadi SH, Ajbani K, Alffenaar JW, Alland D, Alvarez N, Andres S, Ardizzoni E, Aubry A, Baldan R, Ballif M, Barilar I, Böttger EC, Chakravorty S, Claxton PM, Cirillo DM, Comas I, Coulter C, Denkinger CM, Derendinger B, Desmond EP, de Steenwinkel JE, Dheda K, Diacon AH, Dolinger DL, Dooley KE, Egger M, Ehsani S, Farhat MR, Fattorini L, Finci I, Le Ray LF, Furió V, Groenheit R, Gumbo T, Heysell SK, Hillemann D, Hoffmann H, Hsueh PR, Hu Y, Huang H, Hussain A, Ismail F, Izumi K, Jagielski T, Johnson JL, Kambli P, Kaniga K, Eranga Karunaratne G, Sharma MK, Keller PM, Kelly EC, Kholina M, Kohli M, Kranzer K, Laurenson IF, Limberis J, Grace Lin SY, Liu Y, López-Gavín A, Lyander A, Machado D, Martinez E, Masood F, Mitarai S, Mvelase NR, Niemann S, Nikolayevskyy V, Maurer FP, Merker M, Miotto P, Omar SV, Otto-Knapp R, Palaci M, Palacios Gutiérrez JJ, Peacock SJ, Peloquin CA, Perera J, Pierre-Audigier C, Pholwat S, Posey JE, Prammananan T, Rigouts L, Robledo J, Rockwood N, Rodrigues C, Salfinger M, Schechter MC, Seifert M, Sengstake S, Shinnick T, Shubladze N, Sintchenko V, Sirgel F, Somasundaram S, Sterling TR, Spitaleri A, Streicher E, Supply P, Svensson E, Tagliani E, Tahseen S, Takaki A, Theron G, Torrea G, Van Deun A, van Ingen J, Van Rie A, van Soolingen D, Vargas Jr R, Venter A, Veziris N, Villellas C, Viveiros M, Warren R, Wen S, Werngren J, Wilkinson RJ, Yang C, Yılmaz FF, Zhang T, Zimenkov D, Ismail N, Köser CU, Schön T. Updating the approaches to define susceptibility and resistance to anti-tuberculosis agents: implications for diagnosis and treatment. Eur Respir J 2022; 59:2200166. [PMID: 35422426 PMCID: PMC9059840 DOI: 10.1183/13993003.00166-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/05/2022] [Indexed: 11/07/2022]
Abstract
Approximately 85 000 deaths globally in 2019 were due to drug-resistant tuberculosis (TB), which corresponds to 7% of global deaths attributable to bacterial antimicrobial resistance [1]. Yet concerns have been mounting that drug-resistant TB was being underestimated because the approaches to define susceptibility and resistance to anti-TB agents had not kept up with those used for other major bacterial pathogens [2–9]. Here, we outline the recent, evidence-based initiatives spearheaded by the World Health Organization (WHO) and others to update breakpoints (traditionally referred to as critical concentrations (CCs)) that are used for phenotypic antimicrobial susceptibility testing (AST), also called drug susceptibility testing in the TB literature. Inappropriately high breakpoints have resulted in systematic false-susceptible AST results to anti-TB drugs. MIC, PK/PD and clinical outcome data should be combined when setting breakpoints to minimise the emergence and spread of antimicrobial resistance. https://bit.ly/3i43wb6
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15
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Smith-Jeffcoat SE, Sleweon S, Koh M, Khalil GM, Schechter MC, Rebolledo PA, Kasinathan V, Hoffman A, Rossetti R, Shragai T, O'Laughlin K, Espinosa CC, Bankamp B, Bowen MD, Paulick A, Gargis AS, Folster JM, da Silva J, Biedron C, Stewart RJ, Wang YF, Kirking HL, Tate JE. Risk-Factors for Exposure Associated With SARS-CoV-2 Detection After Recent Known or Potential COVID-19 Exposures Among Patients Seeking Medical Care at a Large Urban, Public Hospital in Fulton County, Georgia - A Cross-Sectional Investigation. Front Public Health 2022; 10:809356. [PMID: 35425748 PMCID: PMC9004481 DOI: 10.3389/fpubh.2022.809356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
We aimed to describe frequency of COVID-19 exposure risk factors among patients presenting for medical care at an urban, public hospital serving mostly uninsured/Medicare/Medicaid clients and risk factors associated with SARS-CoV-2 infection. Consenting, adult patients seeking care at a public hospital from August to November 2020 were enrolled in this cross-sectional investigation. Saliva, anterior nasal and nasopharyngeal swabs were collected and tested for SARS-CoV-2 using RT-PCR. Participant demographics, close contact, and activities ≤14 days prior to enrollment were collected through interview. Logistic regression was used to identify risk factors associated with testing positive for SARS-CoV-2. Among 1,078 participants, 51.8% were male, 57.0% were aged ≥50 years, 81.3% were non-Hispanic Black, and 7.6% had positive SARS-CoV-2 tests. Only 2.7% reported COVID-19 close contact ≤14 days before enrollment; this group had 6.79 adjusted odds of testing positive (95%CI = 2.78-16.62) than those without a reported exposure. Among participants who did not report COVID-19 close contact, working in proximity to ≥10 people (adjusted OR = 2.17; 95%CI = 1.03-4.55), choir practice (adjusted OR = 11.85; 95%CI = 1.44-97.91), traveling on a plane (adjusted OR = 5.78; 95%CI = 1.70-19.68), and not participating in an essential indoor activity (i.e., grocery shopping, public transit use, or visiting a healthcare facility; adjusted OR = 2.15; 95%CI = 1.07-4.30) were associated with increased odds of testing positive. Among this population of mostly Black, non-Hispanic participants seeking care at a public hospital, we found several activities associated with testing positive for SARS-CoV-2 infection in addition to close contact with a case. Understanding high-risk activities for SARS-CoV-2 infection among different communities is important for issuing awareness and prevention strategies.
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Affiliation(s)
| | - Sadia Sleweon
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Mitsuki Koh
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - George M. Khalil
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Marcos C. Schechter
- Emory University School of Medicine, Division of Infectious Diseases, Atlanta, GA, United States
- Grady Memorial Hospital, Atlanta, GA, United States
| | - Paulina A. Rebolledo
- Emory University School of Medicine, Division of Infectious Diseases, Atlanta, GA, United States
- Emory University School of Public Health, Hubert Department of Global Health, Atlanta, GA, United States
| | - Vyjayanti Kasinathan
- Emory University School of Medicine, Division of Infectious Diseases, Atlanta, GA, United States
- Grady Memorial Hospital, Atlanta, GA, United States
| | - Adam Hoffman
- Grady Memorial Hospital, Atlanta, GA, United States
- Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA, United States
| | - Rebecca Rossetti
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Talya Shragai
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Kevin O'Laughlin
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Bettina Bankamp
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Michael D. Bowen
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Ashley Paulick
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Amy S. Gargis
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Juliana da Silva
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Caitlin Biedron
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Yun F. Wang
- Grady Memorial Hospital, Atlanta, GA, United States
- Emory University School of Medicine, Pathology & Laboratory Medicine, Atlanta, GA, United States
| | - Hannah L. Kirking
- Centers for Disease Control and Prevention, Atlanta, GA, United States
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16
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O’Laughlin K, Espinosa CC, Smith-Jeffcoat SE, Koh M, Khalil GM, Hoffman A, Rebolledo PA, Schechter MC, Stewart RJ, da Silva J, Biedron C, Bankamp B, Folster J, Gargis AS, Bowen MD, Paulick A, Wang YF, Tate JE, Kirking HL. Specimen self-collection for SARS-CoV-2 testing: Patient performance and preferences—Atlanta, Georgia, August-October 2020. PLoS One 2022; 17:e0264085. [PMID: 35263342 PMCID: PMC8906601 DOI: 10.1371/journal.pone.0264085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 02/02/2022] [Indexed: 11/19/2022] Open
Abstract
Self-collected specimens can expand access to SARS-CoV-2 testing. At a large inner-city hospital 1,082 participants self-collected saliva and anterior nasal swab (ANS) samples before healthcare workers collected nasopharyngeal swab (NPS) samples on the same day. To characterize patient preferences for self-collection, this investigation explored ability, comfort, and ease of ANS and saliva self-collection for SARS-CoV-2 testing along with associated patient characteristics, including medical history and symptoms of COVID-19. With nearly all participants successfully submitting a specimen, favorable ratings from most participants (at least >79% in ease and comfort), and equivocal preference between saliva and ANS, self-collection is a viable SARS-CoV-2 testing option.
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Affiliation(s)
- Kevin O’Laughlin
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
- Epidemic Intelligence Service, CDC, Atlanta, GA, United States of America
- * E-mail:
| | - Catherine C. Espinosa
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Sarah E. Smith-Jeffcoat
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Mitsuki Koh
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - George M. Khalil
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Adam Hoffman
- Grady Memorial Hospital, Atlanta, GA, United States of America
- Emory University Atlanta, Atlanta, GA, United States of America
| | | | - Marcos C. Schechter
- Grady Memorial Hospital, Atlanta, GA, United States of America
- Emory University Atlanta, Atlanta, GA, United States of America
| | - Rebekah J. Stewart
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Juliana da Silva
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Caitlin Biedron
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Bettina Bankamp
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Jennifer Folster
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Amy S. Gargis
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Michael D. Bowen
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Ashley Paulick
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Yun F. Wang
- Grady Memorial Hospital, Atlanta, GA, United States of America
- Emory University Atlanta, Atlanta, GA, United States of America
| | - Jacqueline E. Tate
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Hannah L. Kirking
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
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17
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Aqua JK, Holdsworth J, Burd E, Jacob JT, Ray SM, Schechter MC. Mycobacterium bovis Bacillus Calmette-Guérin Cross-Contamination in the Operating Room: A Case Report. J Investig Med High Impact Case Rep 2021; 9:23247096211066287. [PMID: 34937411 PMCID: PMC8725022 DOI: 10.1177/23247096211066287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Mycobacterium tuberculosis complex (MTBC) false-positive cultures are commonly attributed to laboratory cross-contamination, but cross-contamination in the operating room (OR) is seldom reported. We report an investigation of cross-contamination in the OR for our case patient, who underwent surgical intervention for a chronic, left-sided breast lesion. Although the case patient had never received Mycobacterium bovis bacillus Calmette-Guérin (BCG) vaccine or chemotherapy, a subsequent surgical sample culture was identified as MTBC by high-performance liquid chromatography and M. bovis BCG-type by genotyping. A collaborative false-positive investigation was initiated, and we discovered a cross-contamination event in the OR from a source case who received BCG intravesical instillation. Clinicians, public health, and infection control staff should be aware that MTBC cross-contamination in the OR is rare, but possible, and should recognize the importance of conducting thorough false-positive investigations.
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Affiliation(s)
- Jasmine Ko Aqua
- Emory University, Atlanta, GA, USA.,Georgia Department of Public Health, Atlanta, GA, USA
| | | | | | | | - Susan M Ray
- Emory University, Atlanta, GA, USA.,Georgia Department of Public Health, Atlanta, GA, USA
| | - Marcos C Schechter
- Emory University, Atlanta, GA, USA.,Georgia Department of Public Health, Atlanta, GA, USA
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Rocco JM, Mallarino-Haeger C, Randolph AH, Ray SM, Schechter MC, Zerbe CS, Holland SM, Sereti I. Hyperinflammatory Syndromes After Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Messenger RNA vaccination in Individuals With Underlying Immune Dysregulation. Clin Infect Dis 2021; 75:e912-e915. [PMID: 34893818 PMCID: PMC8689836 DOI: 10.1093/cid/ciab1024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Indexed: 01/19/2023] Open
Abstract
The development of effective severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) messenger RNA (mRNA) vaccines has been a significant accomplishment. Adverse events are extremely rare, but continued surveillance is important, especially in at-risk populations. In 5 patients with preexisting immune dysregulation, hyperinflammatory syndromes, including hemophagocytic lymphohistiocytosis, developed after SARS-CoV-2 mRNA vaccination. Early recognition of this rare condition is essential.
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Affiliation(s)
- Joseph M Rocco
- Correspondence: Joseph M. Rocco, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bldg 10, Room 11B17, MSC 1876, 10 Center Dr, Bethesda, MD 20892 ()
| | | | - Attiya H Randolph
- Department of Medicine, George Washington University of Medicine and Health Sciences, Washington, DC, USA
| | - Susan M Ray
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcos C Schechter
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christa S Zerbe
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Steven M Holland
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Irini Sereti
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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19
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Smith-Jeffcoat SE, Koh M, Hoffman A, Rebolledo PA, Schechter MC, Miller HK, Sleweon S, Rossetti R, Kasinathan V, Shragai T, O'Laughlin K, Espinosa CC, Khalil GM, Adeyemo AO, Moorman A, Bauman BL, Joseph K, O'Hegarty M, Kamal N, Atallah H, Moore BL, Bohannon CD, Bankamp B, Hartloge C, Bowen MD, Paulick A, Gargis AS, Elkins C, Stewart RJ, da Silva J, Biedron C, Tate JE, Wang YF, Kirking HL. Effects of Patient Characteristics on Diagnostic Performance of Self-Collected Samples for SARS-CoV-2 Testing. Emerg Infect Dis 2021; 27:2081-2089. [PMID: 34286681 PMCID: PMC8314823 DOI: 10.3201/eid2708.210667] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We evaluated the performance of self-collected anterior nasal swab (ANS) and saliva samples compared with healthcare worker–collected nasopharyngeal swab specimens used to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We used the same PCR diagnostic panel to test all self-collected and healthcare worker–collected samples from participants at a public hospital in Atlanta, Georgia, USA. Among 1,076 participants, 51.9% were men, 57.1% were >50 years of age, 81.2% were Black (non-Hispanic), and 74.9% reported >1 chronic medical condition. In total, 8.0% tested positive for SARS-CoV-2. Compared with nasopharyngeal swab samples, ANS samples had a sensitivity of 59% and saliva samples a sensitivity of 68%. Among participants tested 3–7 days after symptom onset, ANS samples had a sensitivity of 80% and saliva samples a sensitivity of 85%. Sensitivity varied by specimen type and patient characteristics. These findings can help physicians interpret PCR results for SARS-CoV-2.
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20
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Shragai T, Smith-Jeffcoat SE, Koh M, Schechter MC, Rebolledo PA, Kasinathan V, Wang Y, Hoffman A, Miller H, Tejada-Strop A, Jain S, Tamin A, Harcourt JL, Thornburg NJ, Wong P, Medrzycki M, Folster JM, Semenova V, Steward-Clark E, Drobenuic J, Biedron C, Stewart RJ, da Silva J, Kirking HL, Tate JE. Epidemiologic, immunologic, and virus characteristics in patients with paired SARS-CoV-2 serology and reverse transcription polymerase chain reaction testing. J Infect Dis 2021; 225:229-237. [PMID: 34216468 DOI: 10.1093/infdis/jiab349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/02/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The natural history and clinical progression of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections can be better understood using combined serological and reverse transcription polymerase chain reaction (RT-PCR) testing. METHODS Nasopharyngeal swabs and serum were collected at a single time-point from patients at an urban, public hospital August - November 2020 and tested for SARS-CoV-2 using RT-PCR, viral culture, and anti-Spike pan-Ig antibody testing. Participant demographics and symptoms were collected through interview. Chi-squared and Fisher's exact tests were used to identify associations between RT-PCR and serology results with presence of viable virus and frequency of symptoms. RESULTS Among 592 participants, 129 (21.8%) had evidence of SARS-CoV-2 infection by RT-PCR or serology. Presence of SARS-CoV-2 antibodies was strongly associated with lack of viable virus (p-value=0.016). COVID-19 symptom frequency was similar for patients testing RT-PCR positive/seronegative and patients testing RT-PCR positive/seropositive. Patients testing RT-PCR positive/seronegative reported headaches, fatigue, diarrhea and vomiting at rates not statistically significantly different from those testing RT-PCR negative/seropositive. CONCLUSIONS While patients testing SARS-CoV-2 seropositive were unlikely to test positive for viable virus and were therefore low-risk for forward transmission, COVID-19 symptoms were common. Paired SARS-CoV-2 RT-PCR and antibody testing provides more nuanced understanding of patients' COVID-19 status.
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Affiliation(s)
- Talya Shragai
- Centers for Disease Control and Prevention, Atlanta, GA, 30308, USA
| | | | - Mitsuki Koh
- Centers for Disease Control and Prevention, Atlanta, GA, 30308, USA
| | - Marcos C Schechter
- Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | | | | | - Yun Wang
- Emory University, Atlanta, GA, USA
| | - Adam Hoffman
- Emory University, Atlanta, GA, USA.,Grady Memorial Hospital, Atlanta, GA, USA
| | - Halie Miller
- Centers for Disease Control and Prevention, Atlanta, GA, 30308, USA
| | | | - Shilpi Jain
- Centers for Disease Control and Prevention, Atlanta, GA, 30308, USA
| | - Azaibi Tamin
- Centers for Disease Control and Prevention, Atlanta, GA, 30308, USA
| | | | | | - Phili Wong
- Centers for Disease Control and Prevention, Atlanta, GA, 30308, USA
| | | | | | - Vera Semenova
- Centers for Disease Control and Prevention, Atlanta, GA, 30308, USA
| | | | - Jan Drobenuic
- Centers for Disease Control and Prevention, Atlanta, GA, 30308, USA
| | - Caitlin Biedron
- Centers for Disease Control and Prevention, Atlanta, GA, 30308, USA
| | | | - Juliana da Silva
- Centers for Disease Control and Prevention, Atlanta, GA, 30308, USA
| | - Hannah L Kirking
- Centers for Disease Control and Prevention, Atlanta, GA, 30308, USA
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Abstract
People who inject drugs (PWID) presenting with injection drug use-associated infections are an understudied population excluded from most prospective infectious disease (ID) clinical trials. Careful application of the existing ID literature to PWID must consider their unique medical, psychological, and social challenges. Identification and treatment of the underlying substance use disorder are key underpinnings to any successful ID intervention.
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Affiliation(s)
- David P Serota
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1120 Northwest 14 Street, Suite 851, Miami, FL 33136, USA.
| | - Teresa A Chueng
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1120 Northwest 14 Street, Suite 851, Miami, FL 33136, USA; Jackson Memorial Hospital, Jackson Health System, Miami, FL, USA. https://twitter.com/teresachueng
| | - Marcos C Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University, 49 Jesse Hill Jr Dr SE, Atlanta, GA 30303, USA. https://twitter.com/limbsandlungs
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22
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Fayfman M, Schechter MC, Amobi CN, Williams RN, Hillman JL, Alam MM, Rajani RR, Ziemer DC, Kempker RR, Umpierrez GE. Barriers to diabetic foot care in a disadvantaged population: A qualitative assessment. J Diabetes Complications 2020; 34:107688. [PMID: 32917487 PMCID: PMC10424493 DOI: 10.1016/j.jdiacomp.2020.107688] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/10/2020] [Accepted: 07/17/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE We explored barriers to proper foot care in this population using a qualitative approach with focus group discussions (FGD). METHODS Participants were recruited from clinics at a safety-net hospital in Atlanta, Georgia and stratified into two groups: diabetic foot ulcer (DFU) and minor amputation (below ankle). The FGDs addressed patient experience in receiving care with a goal of understanding: foot care knowledge, barriers to care, and preferred educational methods. Surveys were performed to supplement FGDs. RESULTS Forty participants (90% Black) were enrolled. Dominant themes emerging from FGDs were: 1-Patients reported adequate understanding of recommended foot care practices; 2-Personal barriers to self-care included lack of motivation, high cost, poor insurance coverage of supplies, and difficulty limiting activity for proper offloading; 3-Hospital system barriers included difficulty making timely appointments and reaching a provider to arrange care; 4-Access to footcare-related information and services improved with greater disease severity. Participants stressed that improved access often came too late to alter their course. They expressed interest in developing peer support groups to facilitate learning and sharing information relating to DFU. CONCLUSION We found that patients with DFU or minor amputations have adequate footcare-related knowledge, but personal and systemic barriers limited appropriate foot care.
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Affiliation(s)
- Maya Fayfman
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, GA, United States of America.
| | - Marcos C Schechter
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Infectious Diseases, Atlanta, GA, United States of America
| | - Chimora N Amobi
- Emory Centers for Training and Technical Assistance, Emory University, United States of America
| | - Rebekah N Williams
- Emory Centers for Training and Technical Assistance, Emory University, United States of America
| | - JoAnna L Hillman
- Emory Centers for Training and Technical Assistance, Emory University, United States of America
| | - Muhammad Murtaza Alam
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, GA, United States of America
| | - Ravi R Rajani
- Emory University School of Medicine, Grady Memorial Hospital, Department of Surgery, Division of Vascular Surgery, Atlanta, GA, United States of America
| | - David C Ziemer
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, GA, United States of America
| | - Russell R Kempker
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Infectious Diseases, Atlanta, GA, United States of America
| | - Guillermo E Umpierrez
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, GA, United States of America
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23
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Schechter MC, Ali MK, Risk BB, Singer AD, Santamarina G, Rogers HK, Rajani RR, Umpierrez G, Fayfman M, Kempker RR. Percutaneous Bone Biopsy for Diabetic Foot Osteomyelitis: A Systematic Review and Meta-Analysis. Open Forum Infect Dis 2020; 7:ofaa393. [PMID: 33134407 PMCID: PMC7590897 DOI: 10.1093/ofid/ofaa393] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/24/2020] [Indexed: 12/30/2022] Open
Abstract
Background Diabetes is the leading cause of lower extremity nontraumatic amputation globally, and diabetic foot osteomyelitis (DFO) is usually the terminal event before limb loss. Although guidelines recommend percutaneous bone biopsy (PBB) for microbiological diagnosis of DFO in several common scenarios, it is unclear how frequently PBBs yield positive cultures and whether they cause harm or improve outcomes. Methods We searched the PubMed, EMBASE, and Cochrane Trials databases for articles in any language published up to December 31, 2019, reporting the frequency of culture-positive PBBs. We calculated the pooled proportion of culture-positive PBBs using a random-effects meta-analysis model and reported on PBB-related adverse events, DFO outcomes, and antibiotic adjustment based on PBB culture results where available. Results Among 861 articles, 11 studies met inclusion criteria and included 780 patients with 837 PBBs. Mean age ranged between 56.6 and 71.0 years old. The proportion of males ranged from 62% to 86%. All studies were longitudinal observational cohorts, and 10 were from Europe. The range of culture-positive PBBs was 56%-99%, and the pooled proportion of PBBs with a positive culture was 84% (95% confidence interval, 73%-91%). There was heterogeneity between studies and no consistency in definitions used to define adverse events. Impact of PBB on DFO outcomes or antibiotic management were seldom reported. Conclusions This meta-analysis suggests PBBs have a high yield of culture-positive results. However, this is an understudied topic, especially in low- and middle-income countries, and the current literature provides very limited data regarding procedure safety and impact on clinical outcomes or antibiotic management.
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Affiliation(s)
- Marcos C Schechter
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia, USA
| | - Mohammed K Ali
- Emory University, Rollins School of Public Health, Department of Global Health and Epidemiology, Atlanta, Georgia, USA
| | - Benjamin B Risk
- Emory University, Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Atlanta, Georgia, USA
| | - Adam D Singer
- Emory University School of Medicine, Grady Memorial Hospital, Department of Radiology and Imaging Sciences, Division of Musculoskeletal Imaging, Atlanta, Georgia, USA
| | - Gabriel Santamarina
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, Georgia, USA
| | - Hannah K Rogers
- Emory University, Woodruff Health Sciences Center Library, Information Services, Atlanta, Georgia, USA
| | - Ravi R Rajani
- Emory University School of Medicine, Grady Memorial Hospital, Department of Surgery, Division of Vascular Surgery, Atlanta, Georgia, USA
| | - Guillermo Umpierrez
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, Georgia, USA
| | - Maya Fayfman
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, Georgia, USA
| | - Russell R Kempker
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia, USA
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24
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Singer AD, Umpierrez M, Kakarala A, Schechter MC, Maceroli M, Sharma GB, Rajani RR. Performance of a rapid two-sequence screening protocol for osteomyelitis of the foot. Skeletal Radiol 2020; 49:977-984. [PMID: 31938864 DOI: 10.1007/s00256-019-03367-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/13/2019] [Accepted: 12/22/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Compare a two sequence protocol to a standard protocol in the detection of pedal osteomyelitis (OM) and abscesses and to identify patients that benefit from a full protocol. MATERIALS AND METHODS One hundred thirty-two foot MRIs ordered to assess for OM were enrolled, and the following items were extracted from the clinical reports: use of IV contrast, the presence of OM, reactive osteitis, and a soft tissue abscess. Using only one T1 nonfat-suppressed and one fluid sensitive fat-suppressed sequences, two experienced musculoskeletal radiologists reviewed each case for the presence of OM, reactive osteitis, or an abscess. A Kappa test was calculated to assess for interobserver agreement, and diagnostic performance was determined. The McNemar test was used to assess for the effect of contrast. RESULTS Agreement between both observers and the clinical report on the presence of osteomyelitis was substantial ( k = 0.63 and 0.72, p < 0.001), while the agreement for abscess was fair (k = 0.29 and 0.38, p < 0.001). For osteomyelitis, both observers showed good accuracy (0.85 and 0.86). When screening bone for a normal versus abnormal case, this method was highly sensitive (0.97-0.98), but was less sensitive for abscess (0.63-0.75). Fifty-one percent of exams used contrast, and it did impact the diagnosis of abscess for one observer. CONCLUSION This rapid protocol is accurate in making the diagnosis of OM, and its high sensitivity makes it useful to screen for patients that would benefit from a full protocol.
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Affiliation(s)
- Adam D Singer
- Department of Radiology and Imaging Sciences, Division of Musculoskeletal Imaging, Emory University Hospital, 59 Executive Park South, 4th Floor Suite 4009, Atlanta, GA, 30329, USA.
| | - Monica Umpierrez
- Department of Radiology and Imaging Sciences, Division of Musculoskeletal Imaging, Emory University Hospital, 59 Executive Park South, 4th Floor Suite 4009, Atlanta, GA, 30329, USA
| | - Aparna Kakarala
- Department of Radiology and Imaging Sciences, Division of Musculoskeletal Imaging, Emory University Hospital, 59 Executive Park South, 4th Floor Suite 4009, Atlanta, GA, 30329, USA
| | - Marcos C Schechter
- Department of Medicine, Division of Infectious Disease, Emory University Hospital, Atlanta, GA, USA
| | - Michael Maceroli
- Department of Orthopaedic Surgery, Emory University Hospital, Atlanta, GA, USA
| | | | - Ravi R Rajani
- Department of Surgery, Division of Vascular Surgery, Emory University Hospital, Atlanta, GA, USA
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25
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Bernheim A, Kempker RR, Hernandez-Romieu AC, Schechter MC, Little BP. Internal thoracic lymphadenopathy and pulmonary tuberculosis. Clin Imaging 2020; 67:11-14. [PMID: 32497996 DOI: 10.1016/j.clinimag.2020.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/13/2020] [Accepted: 04/29/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Internal thoracic lymphadenopathy (ITL) has been associated with malignancies and non-tuberculous empyema. However, the association between ITL and active pulmonary tuberculosis (PTB) and the correlation between ITL and other imaging characteristics of active PTB has not been examined. MATERIALS AND METHODS A retrospective cohort study comprising 137 adults with active PTB who had a concomitant chest CT over a seven-year period was conducted. Two thoracic radiologists evaluated for ITL as well as nine other imaging characteristics of active tuberculosis, including total lung involvement (as measured by a total severity score), number of nodules, presence of tree-in-bud nodularity, highest extent of tree-in-bud nodularity in a lobe, miliary pattern, cavitary lesions, pleural effusion, lymphadenopathy (excluding internal thoracic lymph nodes), and empyema. The Wilcoxon rank-sum test and chi-squared tests were used to assess the correlation between ITL and additional imaging findings. RESULTS Internal thoracic lymphadenopathy was present in 50 of 137 cases (36.5%); most commonly bilateral (19.0%) or isolated on the right side (13.7%), and less commonly isolated on the left side (3.7%). Pleural effusion, lymphadenopathy (apart from internal thoracic compartment), and empyema all showed statistically significant correlations with ITL (p-values of <0.0001). CONCLUSIONS While the presence of ITL - particularly when accompanied by other imaging findings such as pleural effusion - may prompt a radiologist to first consider malignancy, active PTB should be an additional consideration in the appropriate clinical context.
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Affiliation(s)
- Adam Bernheim
- Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY 10029, United States of America.
| | - Russell R Kempker
- Division of Infectious Diseases, Emory University School of Medicine, 49 Jesse Hill Jr Drive, Atlanta, GA 30303, United States of America.
| | - Alfonso C Hernandez-Romieu
- Division of Infectious Diseases, Emory University School of Medicine, 341 Ponce De Leon Ave, NE, Atlanta, GA 30322, United States of America.
| | - Marcos C Schechter
- Division of Infectious Diseases, Emory University School of Medicine, 341 Ponce De Leon Ave, NE, Atlanta, GA 30322, United States of America.
| | - Brent P Little
- Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, United States of America.
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26
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Schechter MC, Fayfman M, Khan LSMF, Carr K, Patterson S, Ziemer DC, Umpierrez GE, Rajani R, Kempker RR. Evaluation of a comprehensive diabetic foot ulcer care quality model. J Diabetes Complications 2020; 34:107516. [PMID: 31924527 PMCID: PMC8610099 DOI: 10.1016/j.jdiacomp.2019.107516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/12/2019] [Accepted: 12/26/2019] [Indexed: 12/11/2022]
Abstract
AIMS Diabetes-related amputations are typically preceded by a diabetic foot ulcer (DFU) but models to assess the quality of care are lacking. We investigated a model to measure inpatient and outpatient quality. METHODS Cohort study among adults hospitalized with a DFU to a safety-net hospital during 2016. We measured adherence to DFU-related quality metrics based on guidelines during and 12 months following hospitalization. Inpatient metrics included ankle-brachial index measurement during or 6 months prior to hospitalization, receiving diabetes education and a wound offloading device prior to discharge. Outpatient metrics included wound care ≤30 days of discharge, in addition to hemoglobin A1c (HbA1c) ≤8%, tobacco cessation, and retention in care (≥2 clinic visits ≥90 days apart) 12 months following discharge. RESULTS 323 patients were included. Regarding inpatient metrics, 8% had an ankle brachial index measurement, 37% received diabetes education, and 20% received offloading prior to discharge. Regarding outpatient metrics, 33% received wound care ≤30 days of discharge. Twelve months following discharge, 34% achieved a HbA1c ≤8%, 13% quit tobacco, and 52% were retained in care. Twelve-month amputation-free survival was 71%. CONCLUSIONS Our model demonstrated large gaps in DFU guideline-adherent care. Implementing measures to close these gaps could prevent amputations.
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Affiliation(s)
- M C Schechter
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Infectious Diseases, Atlanta, GA, United States of America.
| | - M Fayfman
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, GA, United States of America
| | - L S M F Khan
- Emory University School of Medicine, Atlanta, GA, United States of America
| | - K Carr
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - S Patterson
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - D C Ziemer
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, GA, United States of America
| | - G E Umpierrez
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, GA, United States of America
| | - R Rajani
- Emory University School of Medicine, Grady Memorial Hospital, Department of Surgery Division of Vascular Surgery, Atlanta, GA, United States of America
| | - R R Kempker
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Infectious Diseases, Atlanta, GA, United States of America
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27
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Mikiashvili L, Kipiani M, Schechter MC, Avaliani Z, Kiria N, Kempker RR. Linezolid use for drug-resistant tuberculosis in Georgia: a retrospective cohort study. Int J Tuberc Lung Dis 2020; 24:436-443. [PMID: 32317069 PMCID: PMC7385591 DOI: 10.5588/ijtld.19.0444] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
SETTING: Data on the long-term use of linezolid (LZD) in the treatment of drug-resistant pulmonary tuberculosis (DR-PTB) are limited.OBJECTIVE: To assess safety, tolerability and efficacy of LZD-containing regimens for the treatment of DR-PTB in the country of Georgia.DESIGN: A retrospective study was conducted among DR-PTB patients receiving LZD 600 mg/day as part of newly implemented regimens (bedaquiline or delamanid, repurposed and second-line drugs) from July 2014 to October 2015 in programmatic conditions and following WHO recommendations.RESULTS: One hundred mostly male (82%) patients with a median age of 33 years received LZD. Most patients (77%) had previously been treated for TB; 57% had extensively drug-resistant TB. The median duration of LZD use was 503 days (interquartile range 355-616). LZD-associated adverse events occurred in 12 patients, leading to discontinuation in 4 (2 each due to peripheral neuropathy and cytopenias), and dose reduction to 300 mg/day in 6 cases (4 due to peripheral neuropathy and 2 for cytopenias). Almost all patients (95%) achieved culture conversion and 79% had a successful treatment outcomes.CONCLUSION: Treatment regimens including lengthy LZD use showed fairly good safety and tolerability and were associated with high rates of culture conversion and favorable outcomes.
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Affiliation(s)
- L Mikiashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - M Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - M C Schechter
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - N Kiria
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - R R Kempker
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
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Schechter MC, Fayfman M, SMF. Khan L, Patterson S, Ziemer D, Umpierrez G, Rajani R, Kempker RR. 459. Gaps in Diabetic Foot Care in an Inner-City Hospital. Open Forum Infect Dis 2019. [PMCID: PMC6809778 DOI: 10.1093/ofid/ofz360.532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Diabetic foot disease is the leading cause of preventable limb loss in the United States. Care continuum models to measure gaps in care are lacking.
Methods
Retrospective cohort study conducted in an urban safety-net hospital in Atlanta, GA (Grady Memorial Hospital). All patients admitted between January-May 2016 with diabetes-related foot ulcer, osteomyelitis, or for lower-extremity amputation were included. A care continuum model for inpatient and post-discharge outpatient metrics was developed based on national guidelines and available diabetes care continuum models (figure). We followed patients for 12 months after initial hospital admission.
Results
Among 123 patients, the median age was 56 (IQR 48–64) years and most were male (67%) and black (83%) (table). Prior to hospital admission, 12% of patients had a major amputation (above ankle) and 21% had a minor amputation (below ankle). Tobacco use (34%), homelessness (29%), and no medical insurance (20%) rates were high. Few patients (28%) had hemoglobin A1c (Hb1Ac) at goal (≤7.5%) and 10% had end-stage renal disease. Regarding inpatient care metrics, 59% had a median glucose at goal on the day of discharge (≤180 gm/dL). Few patient patients had a noninvasive vascular test (13%) or received a wound offloading device (16%) during hospitalization. Regarding post-discharge outpatient metrics, 33% had wound care ≤30 days after hospitalization, 14% with tobacco use at baseline quit, and 24% had Hb1c ≤7.5%. Emergency room (ER) visits and hospital readmissions within 12 months post-discharge were common (77% and 66%, respectively). Only 54% were retained in care (≥2 clinic visits ≥90 days apart). Outcomes during 12 months after the first day of initial hospital admission were poor: 6% died, 23% had a new major amputation and 22% had a new minor amputation. Including major amputations prior to initial hospital admission, 37% of patients died or were living with a major amputation 12 months after hospitalization.
Conclusion
Our care continuum model demonstrated large gaps in diabetic foot care. Over a third of these patients died or were living with major limb loss and there were high rates of ER visits and hospital readmissions. Implementing measures to close gaps in care could improve outcomes.
Disclosures
All authors: No reported disclosures.
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Affiliation(s)
| | - Maya Fayfman
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | - David Ziemer
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Ravi Rajani
- Emory University School of Medicine, Atlanta, Georgia
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Hernandez-Romieu AC, Little BP, Bernheim A, Schechter MC, Ray SM, Bizune D, Kempker R. Erratum to: Increasing Number and Volume of Cavitary Lesions on Chest Computed Tomography Are Associated With Prolonged Time to Culture Conversion in Pulmonary Tuberculosis. Open Forum Infect Dis 2019; 6:ofz443. [PMID: 31667202 PMCID: PMC6814279 DOI: 10.1093/ofid/ofz443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Alfonso C Hernandez-Romieu
- Division of Infectious Disease, School of Medicine, Emory University, Atlanta, Georgia, Boston, Massachusetts
| | - Brent P Little
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Adam Bernheim
- Department of Radiology, School of Medicine, Emory University, Atlanta, Georgia
| | - Marcos C Schechter
- Division of Infectious Disease, School of Medicine, Emory University, Atlanta, Georgia, Boston, Massachusetts
| | - Susan M Ray
- Division of Infectious Disease, School of Medicine, Emory University, Atlanta, Georgia, Boston, Massachusetts
| | - Destani Bizune
- Epidemiology and Statistics Branch, Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Russell Kempker
- Division of Infectious Disease, School of Medicine, Emory University, Atlanta, Georgia, Boston, Massachusetts
- Department of Internal Medicine, School of Medicine, Emory University, Atlanta, Georgia
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Hernandez-Romieu AC, Little BP, Bernheim A, Schechter MC, Ray SM, Bizune D, Kempker R. Increasing Number and Volume of Cavitary Lesions on Chest Computed Tomography Are Associated With Prolonged Time to Culture Conversion in Pulmonary Tuberculosis. Open Forum Infect Dis 2019; 6:ofz232. [PMID: 31263730 PMCID: PMC6590978 DOI: 10.1093/ofid/ofz232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/22/2019] [Indexed: 12/15/2022] Open
Abstract
Background Cavitary lesions (CLs) primarily identified by chest x-ray (CXR) have been associated with worse clinical outcomes among patients with pulmonary tuberculosis (PTB). Chest computed tomography (CT), which has better resolution and increased sensitivity to detect lung abnormalities, has been understudied in PTB patients. We compared detection of CLs by CT and CXR and assessed their association with time to sputum culture conversion (tSCC). Methods This was a retrospective cohort study of 141 PTB patients who underwent CT. We used multivariate Cox proportional hazards models to evaluate the association between CLs on CXR and the number and single largest volume of CLs on CT with tSCC. Results Thirty (21%) and 75 (53%) patients had CLs on CXR and CT, respectively. CT detected cavities in an additional 44 patients (31%) compared with CXR. After multivariable adjustment, we observed a negative association between CLs and tSCC, with an adjusted hazard ratio (aHR) of 0.56 (95% confidence interval [CI], 0.32 to 0.97) for single CLs and 0.31 (95% CI, 0.16 to 0.60) for multiple CLs present on CT. Patients with a CL volume ≥25 mL had a prolonged tSCC (aHR, 0.39; 95% CI, 0.21 to 0.72). CLs on CXR were not associated with increased tSCC after multivariable adjustment. Conclusions CT detected a larger number of cavities in patients with PTB relative to CXR. We observed an association between increasing number and volume of CLs on CT and delayed tSCC independent of sputum microscopy result. Our findings highlight a potential role for CT in the clinical and research setting as a tool to risk-stratify patients with PTB.
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Affiliation(s)
| | - Brent P Little
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Adam Bernheim
- Department of Radiology, School of Medicine, Emory University, Atlanta, Georgia
| | - Marcos C Schechter
- Division of Infectious Disease, School of Medicine, Emory University, Atlanta, Georgia
| | - Susan M Ray
- Division of Infectious Disease, School of Medicine, Emory University, Atlanta, Georgia
| | - Destani Bizune
- Epidemiology and Statistics Branch, Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Russell Kempker
- Division of Infectious Disease, School of Medicine, Emory University, Atlanta, Georgia.,Department of Internal Medicine, School of Medicine, Emory University, Atlanta, Georgia
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Serota DP, Niehaus ED, Schechter MC, Jacob JT, Jones J, Ray SM, Kelley CF, Kempker RR. Disparity in Quality of Infectious Disease vs Addiction Care Among Patients With Injection Drug Use-Associated Staphylococcus aureus Bacteremia. Open Forum Infect Dis 2019; 6:ofz289. [PMID: 31304193 PMCID: PMC6612813 DOI: 10.1093/ofid/ofz289] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 06/17/2019] [Indexed: 11/13/2022] Open
Abstract
Evidence-based interventions for Staphylococcus aureus bacteremia (SAB) are well known, but it is unclear how they are implemented among patients with injection drug use-associated (IDU) SAB. Of 46 patients with IDU-SAB identified, all received high-quality SAB management; however, few received appropriate recognition or treatment of their underlying substance use disorder.
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Affiliation(s)
| | - Emily D Niehaus
- Department of Medical Education, Emory University School of Medicine, Atlanta, Georgia
| | | | - Jesse T Jacob
- Division of Infectious Diseases, Department of Medicine
| | - Jeb Jones
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Susan M Ray
- Division of Infectious Diseases, Department of Medicine.,Grady Health System, Atlanta, Georgia
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Kempker RR, Chkhartishvili N, Kinkladze I, Schechter MC, Harrington K, Rukhadze N, Dzigua L, Tserstvadze T, Del Rio C, Blumberg HM, Tukvadze N. High Yield of Active Tuberculosis Case Finding Among HIV-Infected Patients Using Xpert MTB/RIF Testing. Open Forum Infect Dis 2019; 6:ofz233. [PMID: 31211163 PMCID: PMC6559269 DOI: 10.1093/ofid/ofz233] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/16/2019] [Indexed: 12/23/2022] Open
Abstract
Objective Conduct an active case finding study in Tbilisi, Georgia, for pulmonary tuberculosis (TB) among people living with HIV (PLWH). Methods Newly diagnosed HIV patients were assessed for symptoms and asked to submit sputum samples for smear microscopy, culture, and molecular diagnostic testing (Xpert MTB/RIF). Results Among 276 PLWH, 131 agreed to participate and 103 submitted sputum samples. Most participants were male (70%) and mean age of 43 years. There were high rates of a positive hepatitis C virus (HCV) antibody test (46%) and the median CD4 count was 122 cells/mm3. A total of 15 (11.5%) persons were diagnosed with pulmonary TB, including 1 each with multidrug-resistant and isoniazid-resistant disease. Twelve had a positive culture for Mycobacterium tuberculosis and Xpert TB/RIF assay, and 4 had positive smear microscopy. Patients with pulmonary TB were more likely to use injection drugs (67% vs 36%, P = .02) and have a positive HCV antibody (73% vs 42%, P = .02). The presence and absence of any TB symptom had a sensitivity and negative predictive value for TB of 93% and 98%, respectively. Conclusion Our findings highlight the high prevalence of TB among newly diagnosed HIV-infected patients in an area with high rates of drug-resistant TB and the utility of an active case finding strategy for TB diagnosis.
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Affiliation(s)
- Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Inga Kinkladze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Marcos C Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Nino Rukhadze
- Infectious Diseases, AIDS, and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Lela Dzigua
- Infectious Diseases, AIDS, and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Tengiz Tserstvadze
- Infectious Diseases, AIDS, and Clinical Immunology Research Center, Tbilisi, Georgia
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
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Abraham RS, Albanesi C, Alevizos I, Anguita J, Antiochos B, Aranow C, Atkinson JP, Austin HA, Babu S, Ballow MC, Balow JE, Belmont JW, Berek C, Beukelman T, Bhavsar T, Bird JA, Blutt SE, Boguniewicz M, Bonamichi-Santos R, Boisson B, Borzova E, Boyaka PN, Boyce J, Browne SK, Burks W, Bustamante J, Calder VL, Campbell M, Cardones ARG, Casanova JL, Castells M, Cavacini LA, Chan ES, Chaplin DD, Chatham WW, Chen ES, Chinen J, Christopher-Stine L, Ciancanelli M, Cope AP, Corry DB, Crea F, Cron RQ, Cuellar-Rodriguez JM, Dalakas MC, Dann SM, Diamond B, Du TW, Dupuis-Boisson S, Eagar TN, Elmets CA, Erkan D, Fanning L, Fikrig E, Flego D, Fleisher TA, Fonacier L, Fontenot AP, Freeman AF, Frew AJ, Fujihashi K, Gadina M, Gatt ME, Gershwin ME, Gillespie SL, Goronzy JJ, Goswami S, Grattan CE, Greenspan NS, Gupta S, Gustafson CE, Hall RP, Hamilton RG, Harrington LE, Harrison LC, Hasni SA, Helbling A, Hester J, Holland SM, Hourcade D, Huntington ND, Hwangpo T, Imboden JB, Issa F, Izraeli S, Jaffe ES, Jalkanen S, Jones S, Jouanguy E, Kabbani S, Kaufmann SH, Kheradmand F, Kohn DB, Korngold R, Kovalszki A, Kuhns DB, Kulkarni H, Kuo CY, Lahouti A, Landgren CO, Laurence A, Lee JS, Lemière C, Leung DY, Levinson AI, Levy O, Lewis DE, Lin P, Linkermann A, Liuzzo G, Lockshin MD, Lord AK, Lozier JN, Luong A, Luqmani R, Mackay M, Maltzman JS, Mannon PJ, Manns MP, Martin JG, Maynard CL, McCash S, McDonald DR, Melby PC, Miller SD, Mitchell AL, Mohd-Zaki A, Mold C, Moller DR, Monos DS, Mueller SN, Mulders-Manders CM, Mulligan MJ, Müller UR, Munshi PN, Murata K, Murphy PM, Navasa N, Noel P, Notarangelo LD, Nussbaum RL, Nutman TB, Nutt SL, Oliveira JB, Ortel TL, O'Shea JJ, Pai SY, Pandit L, Paul ME, Pearce SH, Pedicino D, Peterson EJ, Picard C, Pittaluga S, Priel DL, Puck J, Puel A, Radbruch A, Reece ST, Reveille JD, Rich RR, Roifman CM, Rosen A, Rosenbaum JT, Rosenzweig SD, Rouse BT, Rowley SD, Sakaguchi S, Salmi M, Sant AJ, Satola SW, Saw V, Schechter MC, Schroeder HW, Segal BM, Selmi C, Shankar S, Sharma A, Sharma P, Shearer WT, Siegel RM, Simon A, Smith GP, Stephens DS, Stephens R, Straumann A, Teos LY, Timares L, Tonnus W, Torres RM, Uzel G, van der Hilst JC, van der Meer JW, Varga J, Vyas JM, Waldman M, Weiser P, Weller PF, Weyand CM, Wigley FM, Winchester RJ, Wing JB, Wood KJ, Wu X, Xu H, Yee C, Zhang SY. List of Contributors. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00104-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Bizune DJ, Kempker RR, Kagei M, Yamin A, Mohamed O, Holland DP, Oladele A, Wang YF, Rebolledo PA, Blumberg HM, Ray SM, Schechter MC. Treatment Complexities Among Patients with Tuberculosis in a High HIV Prevalence Cohort in the United States. AIDS Res Hum Retroviruses 2018; 34:1050-1057. [PMID: 30105915 DOI: 10.1089/aid.2018.0126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The association between human immunodeficiency virus (HIV) infection and tuberculosis (TB) mortality has been studied extensively, but the impact of HIV on other clinically relevant aspects of TB care such as TB drug-related adverse events (AEs), hospital readmissions, and TB treatment duration is less well characterized. We describe the association of HIV infection with TB clinical complexities and outcomes in a high HIV prevalence cohort in the United States. This is a retrospective cohort study among patients treated for culture-confirmed TB between 2008 and 2015 at an inner-city hospital in Atlanta, GA. Univariate analysis was used to estimate association of HIV with TB treatment interruption due to AEs, hospital readmissions, and treatment duration. Final unfavorable TB treatment outcome was defined as death, loss to follow-up, or recurrent TB. Logistic regression modeling was used to estimate association of HIV with final unfavorable outcomes. Among 274 patients with TB, 96 (35%) had HIV coinfection. HIV-positive patients had more TB treatment interruptions due to AE (34% vs. 15%), were more likely to have a hospital readmission (50% vs. 21%), and received longer TB treatment (9.9 months vs. 8.8 months) compared to HIV-negative patients (p < .01 for all). HIV infection was not associated with final unfavorable outcomes in univariate [odds ratio (OR) = 1.86; confidence interval (95% CI) 0.99-3.49] or multivariate analysis (aOR = 1.13; 95% CI 0.52-2.39) (p ≥ .05 for both). While HIV infection was not associated with final unfavorable TB outcomes, TB/HIV coinfected patients had more complex treatment course underscoring the importance of maintaining resources and expertise to treat coinfected patients in our and similar settings.
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Affiliation(s)
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Aliya Yamin
- Communicable Disease Prevention Branch, Fulton County Board of Health, Atlanta, Georgia
| | - Omar Mohamed
- Communicable Disease Prevention Branch, Fulton County Board of Health, Atlanta, Georgia
| | - David P. Holland
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Communicable Disease Prevention Branch, Fulton County Board of Health, Atlanta, Georgia
| | | | - Yun F. Wang
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
- Department of Pathology, Grady Memorial Hospital, Atlanta, Georgia
| | - Paulina A. Rebolledo
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Henry M. Blumberg
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Susan M. Ray
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Marcos C. Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Serota DP, Kelley C, Jacob JT, Ray SM, Schechter MC, Kempker R. 1020. Injection Drug Use-Associated Staphylococcus aureus Bacteremia in a Large Urban Hospital in Atlanta, Georgia. Open Forum Infect Dis 2018. [PMCID: PMC6255627 DOI: 10.1093/ofid/ofy210.857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Infectious complications of injection drug use (IDU) have increased with the expanding opioid epidemic in the southeast. We assessed the incidence, clinical presentation, and treatment outcomes of IDU-associated Staphylococcus aureus (SA) bacteremia (SAB). Methods We created a retrospective cohort of all adults with community acquired (CA) SAB over 5 years presenting to Grady Memorial Hospital, a 1,000-bed urban county hospital in Atlanta, GA. Charts were reviewed by infectious diseases physicians to obtain clinical and laboratory characteristics, including substance use disorder (SUD), and determine if SAB was IDU-associated. The study period was divided into three periods (P1 = March 2012–January 2014, P2 = January 2014–December 2015, P3 = December 2015–November 2017) to evaluate changes in the incidence of IDU-SAB over time using Poisson regression. Results Among 321 patients with a first episode of CA-SAB, 24 (7%) were IDU-SAB. The number of IDU-SAB cases in each period increased (P1 = 4, P2 = 7, and P3 = 13 [P = 0.07 for trend]). The median age of IDU-SAB patients was 38 (IQR 31–57), 11 (46%) were black, and 15 (63%) had chronic hepatitis C virus infection. Heroin was the most common injected drug (92%) followed by cocaine (25%); multiple drugs were injected in 29%. All but two patients (92%) had a complication of SAB, most commonly endocarditis (50%) and septic pulmonary emboli (38%). The median hospitalization was 23 days (IQR 19.5–37.5) and 5 patients (12%) left the hospital against medical advice (AMA). Readmission for persistent or recurrent SA infection during the study period was common (42%), and three (13%) died ≤6 months from initial presentation, including two with prior discharge AMA. Half of the discharge summaries did not mention SUD as a hospital problem. Outpatient SUD treatment was recommended to eight (33%) patients and a recommendation of abstinence was the intervention for 12 (50%). Conclusion Increasing IDU-SAB was observed over 5 years in our urban Atlanta hospital, primarily due to heroin use. Most cases were associated with complications of SAB with a long length of stay and frequent readmission, but few patients received treatment or harm reduction interventions for their SUD. These data will raise awareness and direct resources to expanding evidence-based opioid use disorder treatment for patients with infectious complications of IDU. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- David P Serota
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Colleen Kelley
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Jesse T Jacob
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Susan M Ray
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Marcos C Schechter
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Russell Kempker
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
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Chida N, Brown C, Mathad J, Carpenter K, Nelson G, Schechter MC, Giles N, Rebolledo PA, Ray S, Fabre V, Cantillo DS, Longworth S, Amorosa V, Petrauskis C, Boulanger C, Cain N, Gupta A, McKenzie-White J, Bollinger R, Melia MT. Internal Medicine Residents' Knowledge and Practice of Pulmonary Tuberculosis Diagnosis. Open Forum Infect Dis 2018; 5:ofy152. [PMID: 30046640 PMCID: PMC6054198 DOI: 10.1093/ofid/ofy152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 06/26/2018] [Indexed: 01/31/2023] Open
Abstract
Background Internal medicine physicians are often the first providers to encounter patients with a new diagnosis of tuberculosis. Given the public health risks of missed tuberculosis cases, assessing internal medicine residents’ ability to diagnose tuberculosis is important. Methods Internal medicine resident knowledge and practice patterns in pulmonary tuberculosis diagnosis at 7 academic hospitals were assessed utilizing (a) a 10-item validated pulmonary tuberculosis diagnosis assessment tool and (b) a retrospective chart review of 343 patients who underwent a pulmonary tuberculosis evaluation while admitted to a resident-staffed internal medicine or infectious disease service. Our primary outcomes were the mean score and percentage of correct responses per assessment tool question, and the percentage of patients who had Centers for Disease Control and Prevention–recommended tuberculosis diagnostic tests obtained. Results Of the 886 residents who received the assessment, 541 responded, yielding a response rate of 61%. The mean score on the assessment tool (SD) was 4.4 (1.6), and the correct response rate was 57% (311/541) or less on 9 of 10 questions. On chart review, each recommended test was obtained for ≤43% (148/343) of patients, other than chest x-ray (328/343; 96%). A nucleic acid amplification test was obtained for 18% (62/343) of patients, whereas 24% (83/343) had only 1 respiratory sample obtained. Twenty patients were diagnosed with tuberculosis. Conclusions Significant knowledge and practice gaps exist in internal medicine residents’ abilities to diagnose tuberculosis. As residents represent the future providers who will be evaluating patients with possible tuberculosis, such deficiencies must be addressed.
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Affiliation(s)
- Natasha Chida
- Johns Hopkins Center for Clinical Global Health Education and Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher Brown
- Department of Medicine, Weill Medical College of Cornell, New York, New York
| | - Jyoti Mathad
- Department of Medicine, Weill Medical College of Cornell, New York, New York
| | - Kelly Carpenter
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - George Nelson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Marcos C Schechter
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Natalie Giles
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Paulina A Rebolledo
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Susan Ray
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Valeria Fabre
- Department of Medicine, Brown University School of Medicine, Providence, Rhode Island
| | - Diana Silva Cantillo
- Department of Medicine, Brown University School of Medicine, Providence, Rhode Island
| | - Sarah Longworth
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Valerianna Amorosa
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Petrauskis
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Catherine Boulanger
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Natalie Cain
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Amita Gupta
- Johns Hopkins Center for Clinical Global Health Education and Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jane McKenzie-White
- Johns Hopkins Center for Clinical Global Health Education and Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert Bollinger
- Johns Hopkins Center for Clinical Global Health Education and Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael T Melia
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Schechter MC, Bizune D, Kagei M, Holland DP, Del Rio C, Yamin A, Mohamed O, Oladele A, Wang YF, Rebolledo PA, Ray SM, Kempker RR. Challenges Across the HIV Care Continuum for Patients With HIV/TB Co-infection in Atlanta, GA [corrected]. Open Forum Infect Dis 2018; 5:ofy063. [PMID: 29657955 PMCID: PMC5890473 DOI: 10.1093/ofid/ofy063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/17/2018] [Indexed: 11/13/2022] Open
Abstract
Background Antiretroviral therapy (ART) for persons with HIV infection prevents tuberculosis (TB) disease. Additionally, sequential ART after initiation of TB treatment improves outcomes. We examined ART use, retention in care, and viral suppression (VS) before, during, and 3 years following TB treatment for an inner-city cohort in the United States. Methods Retrospective cohort study among persons treated for culture-confirmed TB between 2008 and 2015 at an inner-city hospital. Results Among 274 persons with culture-confirmed TB, 96 (35%) had HIV co-infection, including 23 (24%) new HIV diagnoses and 73 (76%) previous diagnoses. Among those with known HIV prior to TB, the median time of known HIV was 6 years, and only 10 (14%) were on ART at the time of TB diagnosis. The median CD4 at TB diagnosis was 87 cells/uL. Seventy-four (81%) patients received ART during treatment for TB, and 47 (52%) has VS at the end of TB treatment. Only 32% of patients had continuous VS 3 years after completing TB treatment. There were 3 TB recurrences and 3 deaths post–TB treatment; none of these patients had retention or VS after TB treatment. Conclusions Among persons with active TB co-infected with HIV, we found that the majority had known HIV and were not on ART prior to TB diagnosis, and retention in care and VS post–TB treatment were very low. Strengthening the HIV care continuum is needed to improve HIV outcomes and further reduce rates of active TB/HIV co-infection in our and similar settings.
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Affiliation(s)
- Marcos C Schechter
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Destani Bizune
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - David P Holland
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia.,Communicable Disease Prevention Branch, Fulton County Health Board of Health, Atlanta, Georgia
| | - Carlos Del Rio
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia.,Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Aliya Yamin
- Communicable Disease Prevention Branch, Fulton County Health Board of Health, Atlanta, Georgia
| | - Omar Mohamed
- Communicable Disease Prevention Branch, Fulton County Health Board of Health, Atlanta, Georgia
| | | | - Yun F Wang
- Department of Pathology and Laboratory Medicine, School of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Pathology, Grady Memorial Hospital, Atlanta, Georgia
| | - Paulina A Rebolledo
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia.,Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Susan M Ray
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
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Schechter MC, Bizune D, Kagei M, Machaidze M, Holland DP, Oladele A, Wang YF, Rebolledo PA, Ray SM, Kempker RR. Time to Sputum Culture Conversion and Treatment Outcomes Among Patients with Isoniazid-Resistant Tuberculosis in Atlanta, Georgia. Clin Infect Dis 2017; 65:1862-1871. [PMID: 29020173 PMCID: PMC5850645 DOI: 10.1093/cid/cix686] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/28/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Although isoniazid-resistant tuberculosis is more common than multidrug-resistant tuberculosis, it has been much less studied. We examined the impact of isoniazid resistance and treatment regimen, including use of a fluoroquinolone, on clinical outcomes. METHODS A retrospective cohort study among patients with sputum culture-positive tuberculosis was performed. Early fluoroquinolone (FQ) use was defined as receiving ≥5 doses during the first month of treatment. The primary outcome was time to sputum culture conversion (tSCC). A multivariate proportional hazards model was used to determine the association of isoniazid resistance with tSCC. RESULTS Among 236 patients with pulmonary tuberculosis, 59 (25%) had isoniazid resistance. The median tSCC was similar for isoniazid-resistant and -susceptible cases (35 vs 29 days; P = .39), and isoniazid resistance was not associated with tSCC in multivariate analysis (adjusted hazard ratio = 0.83; 95% confidence interval [CI], .59-1.17). Early FQ use was higher in isoniazid-resistant than -susceptible cases (20% vs 10%; P = .05); however, it was not significantly associated with tSCC in univariate analysis (hazard ratio = 1.48; 95% CI, .95-2.28). Patients with isoniazid-resistant tuberculosis were treated with regimens containing rifampin, pyrazinamide, and ethambutol +/- a FQ for a median of 9.7 months. Overall, 191 (83%) patients were cured. There was no difference in initial treatment outcomes; however, all cases of acquired-drug resistance (n = 1) and recurrence (n = 3) occurred among patients with isoniazid-resistant tuberculosis. CONCLUSIONS There was no significant association with isoniazid resistance and tSCC or initial treatment outcomes. Although patients with isoniazid-resistant tuberculosis had a high cure rate, the cases of recurrence and acquired drug resistance are concerning and highlight the need for longer-term follow-up studies.
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Affiliation(s)
- Marcos C Schechter
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | | | | | | | - David P Holland
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
- Communicable Disease Prevention Branch, Fulton County Health Department of Health and Wellness, Atlanta
| | | | - Yun F Wang
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine
- Department of Pathology, Grady Memorial Hospital, Atlanta, Georgia
| | - Paulina A Rebolledo
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
- Rollins School of Public Health
| | - Susan M Ray
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
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Schechter MC, Ibegbu CC, Adekambi T, Cagle S, Ray SM, Rengarajan J. Investigation of Plasma IP-10 During Treatment of Pulmonary Tuberculosis. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Schechter MC, Snoeyenbos G, Wang YF, Holland DP, Ray SM. Mycobacteriology Diagnostic Costs in an Inner-City Public Hospital: Are We Ready to Adopt the Xpert MTB/RIF in Lieu of the Acid-Fast Bacilli (AFB) Smear? Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Schechter MC, Workowski KA, Fairley JK. Unusual presentation of chikungunya virus infection with concomintant erysipelas in a returning traveler from the Caribbean: a case report. Open Forum Infect Dis 2014; 1:ofu097. [PMID: 25734165 PMCID: PMC4324224 DOI: 10.1093/ofid/ofu097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 10/02/2014] [Indexed: 12/03/2022] Open
Abstract
Chikungunya fever is a mosquito-borne febrile illness caused by Chikungunya virus (CHIKV), an alphavirus from the Togaviridae family. It is transmitted by primarily Aedes aegytpi and Aedes albopictus mosquitos [1]. Once of little importance in the Americas, local transmission was identified in the Caribbean in late 2013. More than 1000 travelers returning to the continental United States have been diagnosed with CHIKV. More importantly, there have been 9 documented cases of autochthonous disease in Florida as of September 16, 2014 [2].
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Affiliation(s)
- Marcos C Schechter
- Division of Infectious Diseases, Department of Medicine , Emory University School of Medicine
| | - Kimberly A Workowski
- Division of Infectious Diseases, Department of Medicine , Emory University School of Medicine ; Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, US Centers for Disease Control and Prevention , Atlanta , Georgia
| | - Jessica K Fairley
- Division of Infectious Diseases, Department of Medicine , Emory University School of Medicine
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Stauffer F, De Miranda J, Schechter MC, Queiroz FA, Santos NO, Alves AMB, Da Poian AT. New chemical method of viral inactivation for vaccine development based on membrane fusion inhibition. Vaccine 2007; 25:7885-92. [PMID: 17949864 DOI: 10.1016/j.vaccine.2007.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Revised: 08/30/2007] [Accepted: 09/03/2007] [Indexed: 11/15/2022]
Abstract
Membrane fusion is an essential step in the entry of enveloped viruses into their host cells. This process is triggered by conformational changes in viral surface glycoproteins. We have demonstrated previously that modification of vesicular stomatitis virus (VSV) with diethylpyrocarbonate (DEPC) abolished the conformational changes on VSV glycoprotein and the fusion reaction induced by the virus. Moreover, we observed that viral treatment with DEPC inactivates the virus, preserving the conformational integrity of its surface proteins. In the present work, we evaluated the potential use of DEPC as a viral inactivating chemical agent for the development of useful vaccines. Pathogenicity and viral replication in Balb/c mice were abolished by viral treatment with 0.5mM DEPC. In addition, antibodies elicited in mice after intraperitoneal immunization with DEPC-inactivated VSV mixed with adjuvants were able to recognize and neutralize the native virus and efficiently protected animals against the challenge with lethal doses of VSV. These results together suggest that viral inactivation with DEPC seems to be a suitable method for the development of safe vaccines.
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Affiliation(s)
- Fausto Stauffer
- Instituto de Bioquímica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ 21941-590, Brazil
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Stauffer F, De Miranda J, Schechter MC, Carneiro FA, Salgado LT, Machado GF, Da Poian AT. Inactivation of vesicular stomatitis virus through inhibition of membrane fusion by chemical modification of the viral glycoprotein. Antiviral Res 2006; 73:31-9. [PMID: 16934341 DOI: 10.1016/j.antiviral.2006.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Revised: 06/30/2006] [Accepted: 07/11/2006] [Indexed: 11/30/2022]
Abstract
Membrane fusion is an essential step in the entry of enveloped viruses into their host cells triggered by conformational changes in viral glycoproteins. We have demonstrated previously that modification of vesicular stomatitis virus (VSV) with diethylpyrocarbonate (DEPC) abolished conformational changes on VSV glycoprotein and the fusion reaction catalyzed by the virus. In the present study, we evaluated whether treatment with DEPC was able to inactivate the virus. Infectivity and viral replication were abolished by viral treatment with 0.5mM DEPC. Mortality profile and inflammatory response in the central nervous system indicated that G protein modification with DEPC eliminates the ability of the virus to cause disease. In addition, DEPC treatment did not alter the conformational integrity of surface proteins of inactivated VSV as demonstrated by transmission electron microscopy and competitive ELISA. Taken together, our results suggest a potential use of histidine (His) modification to the development of a new process of viral inactivation based on fusion inhibition.
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Affiliation(s)
- Fausto Stauffer
- Instituto de Bioquímica Médica, Programa de Biologia Molecular e Biotecnologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ 21941-590, Brazil
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