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A man in his 40s with no prior orthopaedic history presented to an infectious disease clinic with persistent left knee pain and swelling following a traumatic meniscal tear and ensuing prodromal period of fever and chills. Aspiration of the left knee joint revealed a white cell count of 21.0 ×109/L (83% neutrophils) with negative Gram stain and culture. However, Lyme PCR was positive and accompanied by serologies consistent with Lyme arthritis. He was treated with a standard course of antibiotic therapy with subsequent resolution of joint effusion and significant improvement in pain.This is to our knowledge the first report in the literature of Lyme arthritis seemingly provoked by traumatic knee injury. We propose disruption of normal joint anatomy and ensuing inflammation in response to acute injury incited and accelerated migration of previously latent Borrelia burgdorferi spirochetal infection into surrounding synovial tissue, leading to enhanced inflammatory activity and exacerbation of knee pain.
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Artritis Infecciosa , Borrelia burgdorferi , Enfermedad de Lyme , Masculino , Humanos , Líquido Sinovial , Enfermedad de Lyme/complicaciones , Enfermedad de Lyme/diagnóstico , Enfermedad de Lyme/tratamiento farmacológico , Membrana Sinovial , Antibacterianos/uso terapéutico , Artritis Infecciosa/diagnóstico , Artritis Infecciosa/tratamiento farmacológico , Artritis Infecciosa/etiologíaRESUMEN
Objective: We developed an implementation plan to integrate diagnostic testing for coronavirus disease 2019 (COVID-19) into a public school system. Implementation barriers were identified and strategies were mapped to overcome them. Design: A COVID-19 diagnostic testing program leveraging a public-private partnership was developed for a public school system. Setting: A suburban school district and a local hospital during the 2020-2021 academic year. Methods: Using Consolidated Framework for Implementation Research (CFIR) constructs and evidenced-based implementation strategies, the program was designed as a "closed system" and was adapted based on stakeholder feedback. Implementation barriers and facilitators were identified and mapped to CFIR constructs to provide insights into factors influencing program adoption. Results: Preimplementation stages of engagement, feasibility, and readiness planning were completed. The program did not progress to implementation due to multiple factors, including changes in school leadership (inner setting and process-level constructs), improved access to outside testing, and lack of an existing paradigm for in-school testing (external constructs). Limited support from key stakeholders and opinion leaders was also a barrier (process-level construct). Conclusions: Although this locally initiated program did not progress beyond the preimplementation stage, the processes developed and barriers identified may be useful to inform planning efforts in other testing programs within public school systems. Future programs may consider incorporating multiplex diagnostic testing for influenza in addition to COVID-19. With relaxation of infection control measures, the prevalence of other respiratory viruses will increase. Actionable results will be needed to inform decisions about closures and quarantines.
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BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic may have affected the preventability of 30-day hospital revisits, including readmissions and emergency department (ED) visits without admission. This study was conducted to examine the preventability of 30-day revisits for patients admitted with COVID-19 in order to inform the design of interventions that may decrease preventable revisits in the future. METHODS: The study team retrospectively reviewed a cohort of adults admitted to an academic medical center with COVID-19 between March 21 and June 29, 2020, and discharged alive. Patients with a 30-day revisit following hospital discharge were identified. Two-physician review was used to determine revisit preventability, identify factors contributing to preventable revisits, assess potential preventive interventions, and establish the influence of pandemic-related conditions on the revisit. RESULTS: Seventy-six of 576 COVID-19 hospitalizations resulted in a 30-day revisit (13.2%), including 21 ED visits without admission (3.6%) and 55 readmissions (9.5%). Of these 76 revisits, 20 (26.3%) were potentially preventable. The most frequently identified factors contributing to preventable revisits were related to the choice of postdischarge location and to patient/caregiver understanding of the discharge medication regimen, each occurring in 25.0% of cases. The most frequently cited potentially preventive intervention was "improved self-management plan at discharge," occurring in 65.0% of cases. Five of the 20 preventable revisits (25.0%) had contributing factors that were thought to be directly related to the COVID-19 pandemic. CONCLUSION: Although only approximately one quarter of 30-day hospital revisits following admission with COVID-19 were potentially preventable, these results highlight opportunities for improvement to reduce revisits going forward.
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COVID-19 , Pandemias , Centros Médicos Académicos , Adulto , Cuidados Posteriores , Servicio de Urgencia en Hospital , Hospitales , Humanos , Alta del Paciente , Readmisión del Paciente , Estudios Retrospectivos , SARS-CoV-2RESUMEN
BACKGROUND: Case reports, case series and cohort studies have been published describing the clinical course and outcomes of people living with human immunodeficiency virus (PLWH) who contract coronavirus disease 2019 (COVID-19) pneumonia. However, the majority of the published work focuses on patients with well-controlled human immunodeficiency virus (HIV) on antiretroviral therapy (ART). CASE PRESENTATION: We present a case of a new diagnosis of HIV with Acquired Immune Deficiency Syndrome (AIDS) made simultaneously to diagnosis of COVID-19, with co-infection with pneumocystis jirovecii pneumonia (PJP) and possible cytomegalovirus (CMV) pneumonitis. The patient decompensated following initiation of ART, suggestive of possible immune reconstitution inflammatory syndrome (IRIS). CONCLUSIONS: This case illustrates the importance of maintaining a high suspicion for HIV/AIDS in patients with risk factors. Additionally, this case raises the possibility that IRIS may develop in the setting of ART initiation in patients with COVID-19.
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People with opioid use disorder (OUD) have worse hospital outcomes and higher healthcare costs. There are rising reports of people with OUD also using other classes of drugs, however patterns of substance use have not been evaluated for differential effects on hospital outcomes. We performed a data-analysis of the Healthcare Utilization Project's National Readmissions Database, examining the effects of patterns of substance use, age, gender, and diagnosis on the outcomes of Against Medical Advice (AMA) discharges and 30-day readmissions. About one-third of the patients with OUD who were admitted to the hospital had at least one additional substance use disorder (SUD). Thirteen percent of persons with OUD were discharged AMA, and 12% were readmitted to the hospital within 30 days of discharge. Compared to people with OUD alone, people who used stimulants had increased odds of AMA discharge (aOR 1.83 (CI 1.73, 1.96)) and 30-day readmission (aOR 1.30 (95% CI 1.23, 1.37)). Multiple concomitant substance use disorders were associated with increased odds of AMA discharge and 30-day readmission. Conclusions: People with OUD have high rates of both AMA discharges and 30 day-readmissions, and there is a layered effect of increasing co-occurring SUDs leading to worse hospitalization outcomes. The heterogeneity of drug use patterns needs to be considered when developing strategies to improve health care outcomes for people with substance use disorder.
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Hospitalización , Preparaciones Farmacéuticas , Humanos , Alta del Paciente , Readmisión del Paciente , Estudios RetrospectivosRESUMEN
Illicit drug use can result in a wide range of medical complications. As the availability, synthesis, and popularity of illicit drugs evolve over time, new syndromes associated with their use may mimic infections. Some of these symptoms are anticipated drug effects, and others are complications of adulterants mixed with drugs or complications from the method of using drugs. Some illicit drugs are associated with rare infections, which are difficult to diagnosis with standard microbiological techniques. The goal of this review is to orient a wide range of clinicians-including general practitioners, emergency medicine providers, and infectious diseases specialists-to complications of illicit drug use that may be underrecognized. Improving awareness of infectious and noninfectious complications of illicit drug can expedite diagnosis and medical treatment of persons who use drugs and facilitate targeted harm reduction counseling to prevent future complications.
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Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/epidemiología , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/patología , Drogas Ilícitas/efectos adversos , Abuso de Sustancias por Vía Intravenosa/complicaciones , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/diagnóstico , HumanosRESUMEN
Various biochemical and genomic mechanisms are considered to be a hallmark of metabolic remodeling in the stressed heart, including the hypertrophied and failing heart. In this study, we used quantitative proteomic 2-D Fluorescence Difference In-Gel Electrophoresis (2-D DIGE) in conjunction with mass spectrometry to demonstrate differential protein expression in the hearts of transgenic rabbit models of Long QT Syndrome 1 (LQT1) and Long QT Syndrome 2 (LQT2) as compared to littermate controls (LMC). The results of our proteomic analysis revealed upregulation of key metabolic enzymes involved in all pathways associated with ATP generation, including creatine kinase in both LQT1 and LQT2 rabbit hearts. Additionally, the expression of lamin-A protein was increased in both LQT1 and LQT2 rabbit hearts as was the expression of mitochondrial aldehyde dehydrogenase and desmoplakin in LQT1 and LQT 2 rabbit hearts, respectively. Results of the proteomic analysis also demonstrated down regulation in the expression of protein disulfide-isomerase A3 precuorsor and dynamin-like 120 kDa protein (mitochondrial) in LQT1, and of alpha-actinin 2 in LQT2 rabbit hearts. Up regulation of the expression of the enzymes associated with ATP generation was substantiated by the results of selective enzyme assays in LQT1 and LQT2 hearts, as compared to LMC, which revealed increases in the activities of glycogen phosphorylase (+50%, +65%, respectively), lactate dehydrogenase (+25%, +25%) pyruvate dehydrogenase (+31%, +22%), and succinate dehydrogenase (+32%, +60%). The activity of cytochrome c-oxidase, a marker for the mitochondrial function was also found to be significantly elevated (+80%) in LQT1 rabbit hearts as compared with LMC. Western blot analysis in LQT1 and LQT2 hearts compared to LMC revealed an increase in the expression of very-long chain-specific acyl-CoA dehydrogenase (+35%, +33%), a rate-limiting enzymes in ß-oxidation of fatty acids. Collectively, our results demonstrate similar increases in the expression and activities of key ATP-generating enzymes in LQT1 and LQT2 rabbit hearts, suggesting an increased demand, and in turn, increased energy supply across the entire metabolic pathway by virtue of the upregulation of enzymes involved in energy generation.