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Cardiovascular involvement in idiopathic inflammatory myopathies (IIM) is an understudied area which is gaining increasing recognition in recent times. Recent advances in imaging modalities and biomarkers have allowed the detection of subclinical cardiovascular manifestations in IIM. However, despite the availability of these tools, the diagnostic challenges and underestimated prevalence of cardiovascular involvement in these patients remain significant. Notably, cardiovascular involvement remains one of the leading causes of mortality in patients with IIM. In this narrative literature review, we outline the prevalence and characteristics of cardiovascular involvement in IIM. Additionally, we explore investigational modalities for early detection of cardiovascular involvement, as well as newer approaches in screening to facilitate timely management. Key points• Cardiac involvement in IIM in majority cases is subclinical and a major cause of mortality.• Cardiac magnetic resonance imaging is sensitive for detection of subclinical cardiac involvement.

BackgroundCoronavirus disease 2019 (COVID-19)–associated pulmonary aspergillosis (CAPA) is a potential complication in critically ill COVID-19 patients. Corticosteroids are standard of care for hospitalized COVID-19 patients but carry an increased risk of secondary infections including CAPA. The objective of this study was to evaluate if duration of corticosteroid therapy ≤10 days versus >10 days affects the risk of developing CAPA.MethodsThis was a retrospective cohort study of adult patients with severe COVID-19 pneumonia requiring mechanical ventilation who received at least 3 days of corticosteroid treatment. Incidence of CAPA and secondary outcomes were compared using appropriate bivariable analyses. Steroid duration was evaluated as an independent predictor in a logistic regression model.ResultsA total of 278 patients were included (n = 169 for ≤10 days’ steroid duration; n = 109 for >10 days). CAPA developed in 20 of 278 (7.2%) patients. Patients treated with >10 days of corticosteroid therapy had significantly higher incidence of CAPA (11.9% vs 4.1%; P = .0156), and steroid duration >10 days was independently associated with CAPA (odds ratio, 3.17 [95% confidence interval, 1.02–9.83]). Secondary outcomes including inpatient mortality (77.1% vs 43.2%; P < .0001), mechanical ventilation–free days at 28 days (0 vs 1.5; P < .0001), and secondary infections (44.9% vs 28.4% P = .0220) were worse in the >10 days cohort.ConclusionsCorticosteroid treatment >10 days in critically ill COVID-19 patients is associated with an increased risk of CAPA. Patients may require corticosteroids for reasons beyond COVID-19 and clinicians should be cognizant of risk of CAPA with prolonged courses.

Background and aims Randomized clinical trials have proven the efficacy and safety of Food and Drug Administration (FDA) approved anti-obesity medications (AOMs) for long-term use. It is unclear whether these outcomes can be replicated in real-world clinical practice where clinical complexities arise. The aim of this study was to evaluate the effectiveness and side effects of these medications in real-world multidisciplinary clinical practice settings. Methods We reviewed the electronic medical records (EMR) of patients with obesity who were prescribed an FDA-approved AOM for long-term use in academic and community multidisciplinary weight loss programs between January 2016 and January 2020. Intervention We assessed percentage total body weight loss (%TBWL), metabolic outcomes, and side effect profile up to 24 months after AOM initiation. Results The full cohort consisted of 304 patients (76% women, 95.2% White, median age of 50 years old [IQR, 39-58]). The median follow-up time was 9.1 months [IQR, 4.2-14.1] with a median number of 3 visits [IQR, 2-4]. The most prescribed medication was phentermine/topiramate extended-release (ER) (51%), followed by liraglutide (26.3%), bupropion/naltrexone sustained-release (SR) (16.5%), and lorcaserin (6.2%). %TBWL was 5.0%, 6.8%, 9.3%, 10.3%, and 10.5% at 3, 6, 12, 18, and 24 months. 60.2% of the entire cohort achieved at least 5% TBWL. Overall, phentermine/topiramate-ER had the most robust weight loss response during follow-up, with the highest %TBWL at 12 months of 12.0%. Adverse events were reported in 22.4% of patients. Only 9% of patients discontinued the medication due to side effects. Conclusions AOMs resulted in significant long-term weight loss, that was comparable to outcomes previously reported in clinical trials.

1. Cassandra Mooney, MD* 2. Meera Shah, MD, MPH* 3. Gargi Mukherjee, MD* 1. *Emory University/Children’s Healthcare of Atlanta, Atlanta, GA A 6-week-old boy, born at 38 weeks via normal spontaneous vaginal delivery to a first-time mother, presents to the emergency department with a newly developing rash during the past 2 weeks. Initially described as transient, erythematous, macular, and blanching, it began on his face and spread to his trunk and upper extremities. A rash in the diaper area also appeared concurrently with the rash on his face. He was seen by his pediatrician 10 days before presentation and was prescribed 1% hydrocortisone ointment, nystatin, and bacitracin for the diaper rash. The lesions on his face, trunk, and extremities, believed to be urticarial, were not treated, and his parents were told to monitor for further spread. Three days later the diaper rash resolved, but the other lesions remained. Hydrocortisone was applied to the remaining lesions for 2 days without improvement. Because the lesions continued to increase in number, he was brought to the emergency department. Review of systems is negative for fever, fussiness, vomiting, diarrhea, decreased appetite, and decreased urine output. The mother denies exposure to known sick contacts and changes to soaps or lotions. In addition, there were no complications during the pregnancy; the mother’s routine laboratory values to screen for infection, including human immunodeficiency virus, syphilis, group B Streptococcus, and hepatitis B, were negative. The mother does have a history of cold sores, but none during pregnancy or postpartum. Otherwise, there is no significant family history reported. In the emergency department the patient is nontoxic appearing with the following vital signs: temperature, 99°F (37.2°C); respiratory rate, 44 breaths/min; heart rate, 131 beats/min; blood pressure, 80/40 mm Hg; and oxygen saturation, 99%. His weight is 9.08 lb (4.12 kg) (5th percentile) and length is 20 in (51 cm) (

The shift towards an obese phenotype in celiac disease (CD) patients increases risk of morbidity and mortality. Bariatric surgery (BS) is the gold standard treatment for obesity. Few studies have explored the role of BS in patients with CD. This study aimed to assess the effectiveness and safety of BS in this population. This is a retrospective matched case-control (1:5) study of adult patients with confirmed CD who underwent BS at our institution from 1998 to 2018. Demographics, operative data, post-operative outcomes, complications, and nutritional parameters were collected. Seventy-eight patients (mostly Caucasian females) were included. Thirteen had confirmed CD and were compared with 65 controls. The most common type of BS was the RYGB. The percent of total body weight loss (%TWL) was similar for both groups at 6, 12, 18, 24, and 36 months, with the highest weight loss being at 12 months: %TWL 28.4 (20.2–38.4) for CD, n=13; vs. 29.1 (19.6–39.3) for non-CD, n=49; p=0.8. Obesity-associated co-morbidities greatly and comparably improved in both groups. Patients with CD had no complications after BS. Post-BS malodorous and oily stools were more common among patients with CD (23.1% vs. 4.6%, p=0.03). Micronutrient deficiencies were common and comparable among both groups with iron and vitamin D being the most common deficiencies. Gluten-free diet (GFD) non-adherence post-operatively was associated with a higher incidence of post-BS abdominal pain (60.0% vs. 0.0%, p=0.012). BS is safe and effective in patients with CD. Close monitoring is necessary to ensure compliance with GFD and vitamin supplementation. • Bariatric surgery leads to significant weight loss in celiac disease (CD) patients. • Mid- and long-term weight loss does not differ between patients with and without CD. • Obesity-associated co-morbidities significantly improve after surgery in CD patients. • The incidence of post-surgical complications is not higher in CD patients.

BACKGROUND The management of acute pancreatitis (AP) in children was historically derived from adult practice recommendations. Pediatric-specific recommendations for treatment of AP were recently developed by North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, but their impact on clinical outcomes has yet to be evaluated. We developed an AP order set on the basis of these recommendations to assess impact on clinical outcomes. METHODS Patients admitted to a single center with 3 children’s hospitals in 2017 and 2018 for isolated AP were included in a retrospective review. Patient demographic data, order set use, treatment variables (eg, fluid type, rate, type and timing of diet initiation, and narcotic use), and outcome variables (eg, length of stay [LOS], PICU admission, and 30-day readmission) were collected. Mixed-effects modeling was used to estimate the impact of order set use on clinical outcomes. RESULTS There were 159 pancreatitis encounters and 137 unique patients who met inclusion criteria. In 2018, when using the log transform of LOS in a linear mixed-effects model for clustering by hospital, there was a 10% decrease in mean LOS, but this failed to reach statistical significance (P = .30). Among the 107 encounters who received at least 1 dose of narcotic, there were significantly fewer doses prescribed after implementation of the order set: mean (SD) of5.22 (2.86) vs 3.59 (2.47) (P < .001). Thirty-day readmission (P = .25) and PICU admission rates (P = .31) were not different between years. CONCLUSIONS The implementation of a pancreatitis order set is associated with a significant decrease in narcotic use in pediatric patients with AP without increasing readmission rates or PICU admissions.

OFPs and other health care professionals experience increased rates of stress, anxiety, fatigue and burnout in the face of pandemics. Historically, this has been observed with other pandemics, such as the influenza pandemic, HIV/AIDS, SARS, H1N1, Ebola virus disease and, more recently, COVID-19. Research about physician wellbeing during prior pandemics has informed recent practices and provides more guidance on how larger health care entities can provide for employees and how physicians can care for themselves. Here, we explore best practices for emotional/spiritual wellbeing, physical wellbeing, maintaining a healthy family life and wellness during a virus outbreak.

Exchange processes which include conformational change, protonation/deprotonation, and binding equilibria are routinely studied by 2D exchange NMR techniques, where information about the exchange of nuclei between environments with different NMR shifts is obtained from the development of cross-peaks. Whereas 2D NMR enables the real time study of millisecond and slower exchange processes, 2D ESR in the form of 2D-ELDOR (two-dimensional electron–electron double resonance) has the potential for such studies over the nanosecond to microsecond real time scales. Cross-peak development due to chemical exchange has been seen previously for semiquinones in ESR, but this is not possible for most common ESR probes, such as nitroxides, studied at typical ESR frequencies because, unlike NMR, the exchanging states yield ESR signals that are not resolved from each other within their respective line widths. But at 95 GHz, it becomes possible to resolve them in many cases because of the increased g-factor resolution. The 95 GHz instrumental developments occurring at ACERT now enable such studies. We demonstrate these new capabilities in two studies: (A) the protonation/deprotonation process for a pH-sensitive imidazoline spin label in aqueous solution where the exchange rate and the population ratio of the exchanging states are controlled by the concentration and pH of the buffer solution, respectively, and (B) a nitroxide radical partitioning between polar (aqueous) and nonpolar (phospholipid) environments in multilamellar lipid vesicles, where the cross-peak development arises from the exchange of the nitroxide between the two phases. This work represents the first example of the observation and analysis of cross-peaks arising from chemical exchange processes involving nitroxide spin labels.

Active smoking and secondhand smoke (SHS) exposure increase the risk of cardiovascular morbidity and mortality. Active smoking is associated with reduced levels of omega-3 polyunsaturated fatty acids (n-3 PUFA) and studies show that n-3 PUFA supplementation can improve smoking-induced vascular dysfunction. However, the relationship between n-3 PUFA and SHS exposure has not been studied. Fat-1 transgenic mice, which convert n-6 to n-3 PUFA, were fed diets with n-3 PUFA or without (n-6 PUFA diet), exposed to air or SHS for 4 weeks, and vasoreactivity, antioxidant indices, and omega-3 index (percent eicosapentaenoic + docosahexaenoic acids in RBC) measured. Compared to air-exposed mice, SHS-enhanced aortic constriction in mice fed the n-6 PUFA diet (omega-3 index, 5.9 ± 0.2%; mean ± SE), but not in mice fed the n-3 PUFA diet (omega-3 index, 7.8 ± 0.6%). SHS also significantly induced mRNA expression of cytochrome P4501A1, NADPH:quinone oxidoreductase, heme oxygenase-1, and angiotensinogen in adipose tissue, and increased antioxidant capacity only in mice on the n-6 PUFA diet. Notably, SHS reduced the omega-3 index by 1.0 percentage point (p = 0.003), compared to air-exposed mice irrespective of diet. Additionally, we recruited human nonsmokers (NS) with and without SHS exposure (n = 40) 19–40 years old and measured the omega-3 index and antioxidant capacity. In human subjects SHS exposure was associated with a significantly lower omega-3 index (NS, 4.4 ± 1.1%; NS + SHS, 3.2 ± 1.0%; mean ± SD, p = 0.002) and higher antioxidant capacity (p

Setting Primary care is the first line of defence in healthcare, particularly during the coronavirus disease 2019 (COVID-19) pandemic. In the London-Middlesex region of Ontario, a critical shortage of personal protective equipment (PPE) was identified among primary care physicians (PCPs). Intervention With the help of the London-Middlesex Primary Care Alliance, volunteer administrators, physicians and medical students coordinated the acquisition and redistribution of community-donated PPE to PCPs across London-Middlesex. Our scope evolved to include PPE reusability and stewardship and PCP wellness. Outcome Beginning on March 16, 2020, our initial four-week operation provided PPE to over 200 PCPs. We received 60 donations, including over 118,000 gloves, 13,700 masks, 700 wellness kits and reusable cloth masks and gowns. Each delivery included educational pamphlets, and our online PPE stewardship session was attended by over 30 physicians. Implications In response to the PPE shortage in COVID-19, our efforts evolved into a complex adaptive system, supported by an organizational body with a pre-existing communication infrastructure, to great success. Our scope extended beyond simple PPE provision to PCPs. Furthermore, our initiative established a framework for a centralized response to PPE shortage in Ontario Health West.

Background The rising incidence of infective endocarditis (IE) among people who inject drugs (PWID) has been a major concern across North America. The coincident rise in IE and change of drug preference to hydromorphone controlled-release (CR) among our PWID population in London, Ontario intrigued us to study the details of injection practices leading to IE, which have not been well characterized in literature. Methods A case–control study, using one-on-one interviews to understand risk factors and injection practices associated with IE among PWID was conducted. Eligible participants included those who had injected drugs within the last 3 months, were > 18 years old and either never had or were currently admitted for an IE episode. Cases were recruited from the tertiary care centers and controls without IE were recruited from outpatient clinics and addiction clinics in London, Ontario. Results Thirty three cases (PWID IE+) and 102 controls (PWID but IE-) were interviewed. Multivariable logistic regressions showed that the odds of having IE were 4.65 times higher among females (95% CI 1.85, 12.28; p = 0.001) and 5.76 times higher among PWID who did not use clean injection equipment from the provincial distribution networks (95% CI 2.37, 14.91; p p = 0.197). Discussion Our study highlights the importance of distributing clean injection materials for IE prevention. Furthermore, our study showcases that females are at higher risk of IE, which is contrary to the reported literature. Gender differences in injection techniques, which may place women at higher risk of IE, require further study. We suspect that the very high prevalence of hydromorphone-CR use made our sample size too small to identify a significant association between its use and IE, which has been established in the literature.

Diabetes mellitus type 2 (DM2) remission after bariatric surgery has long been reported in the medical literature. Glucocorticoid use is associated with weight gain and could theoretically affect diabetes remission post bariatric surgery.The aim is to identify remission rates of DM2 among patients using glucocorticoids after bariatric surgery and assess long-term postsurgical follow-up.A retrospective analysis was performed on patients who used glucocorticoids and underwent bariatric surgery at the Mayo Clinic between 2008 and 2020. Data were analyzed for 3-month, 6-month, 1-year, 2-year, and 5-year intervals for factors indicative of diabetes remission.Within our retrospective search, we identified 92 patients who were on any immunosuppressant medication before surgery. Of those, 22 patients had a diagnosis of DM2 while 18 of them were concurrently on glucocorticoids. Diabetes remission occurred in 11 of the 18 DM2 patients (61.11%). There was a statistically significant negative correlation between diabetes remission and combination therapy with glucocorticoids and tacrolimus (P=0.016); patients with a longer duration of DM2 diagnosis (P=0.024), and patients who used insulin three months after the procedure (P=0.001). However, percent total weight loss and the number of preoperative oral DM2 medications were not associated with worse outcomes.Patients who use systemic glucocorticoids are able to achieve diabetes remission after bariatric surgery. Concurrent therapy with tacrolimus is associated with worse remission outcomes.

Background: Modern hepatitis C virus (HCV) treatment regimens yield cure rates greater than 90%. However, obtaining approval for treatment through the prior authorization (PA) process can be time consuming and require extensive documentation. Lack of experience with this complex process can delay HCV medication approval, ultimately increasing the amount of time before patients start treatment and in some cases, prevent treatment altogether. Objectives: Assess the impact of incorporating clinical pharmacists into specialty pharmacy and hepatology clinic services on medication access, patient adherence, and outcomes in patients being treated for HCV. Methods: We performed a retrospective cohort exploratory study of patients seen in an academic medical center hepatology clinic who had HCV prescriptions filled between 8/1/15 and 7/31/17. Patients were categorized by whether they filled prescriptions prior to (Pre-Group) or after (Post-Group) the implementation of a pharmacist in clinic. The Post-Group was further divided according to whether the patient was seen by a pharmacist in clinic (Post-Group 2) or if the patient was not seen by the pharmacist, but had their HCV therapy evaluated by the pharmacist before seeking insurance approval (Post-Group 1). Results: The mean time from the prescription being ordered to being dispensed was longer in the Pre-Group (50.8 ± 66.5 days) compared to both Post-Groups (22.2 ± 27.8 days in Post-Group 1 vs 18.9 ± 17.7 days in Post-Group 2; P

Adolescents aged 13-24 years account for 23% of new HIV infections in Atlanta, indicating need for better HIV prevention strategies in this population. Pre-exposure prophylaxis (PrEP) is now approved for adolescent use. This study aims to understand the acceptability of and barriers to PrEP in adolescents and parents. We administered PrEP acceptability and barrier measures to HIV(-) 13-17 year olds and their parents from January to April 2016 in an adolescent clinic and emergency department in Atlanta, GA, stratifying by adolescent sexual activity. Acceptability scores (AS) and barrier scores (BS) were calculated by averaging survey answers 1-3. For AS, 1 was very unlikely to accept PrEP; concomitantly, BS near 3 indicated fewer barriers. Two-sample hypothesis testing, Pearson correlations, and linear regression were used. Of the 102 adolescent/parent dyads, 67% of adolescents were female, 94% black, with a mean age of 15.7 ± 1.5 years, and 31% were sexually active. Parents were 94% female, 96% black, with a mean age of 42.4 ± 8.9 years. AS averaged between somewhat to very likely to accept PrEP (2.4 ± 0.5 and 2.2 ± 0.6) in adolescents and parents, respectively. BS averaged between unlikely and somewhat likely to perceive barriers to PrEP (2.0 ± 0.4 and 1.9 ± 0.5) in adolescents and parents, respectively. The adolescent/parent dyad is likely to accept PrEP, regardless of sexual activity. Limitations include that nearly 70% of adolescents were not sexually active, and the study was conducted before PrEP approval by the Food and Drug Administration for those who are younger than 18 years. These results support future parent and adolescent education on PrEP.

Purpose: To examine the relationship between post-natal growth and development of retinopathy of prematurity (ROP) among preterm infants in southwestern Ontario. Methods: The medical records of 431 preterm infants, born between January 1, 2008, and June 1, 2015, with a gestational age (GA) of less than 31 weeks or birth weight (BW) of less than 1,250 g were reviewed. Information collected included pregnancy and birth history, neonatal characteristics, ROP status, comorbidities, and postnatal weight measurements at specified intervals. Infants diagnosed as having ROP and no ROP were compared. Results: Low weight velocity from day 7 to day 28 ( P < .001), high weight velocity from birth to first day of full enteral feeding (FEF) ( P < .001), long duration from birth to FEF ( P < .001), and long duration from FEF to discharge/transfer ( P < .001) were associated with ROP. After controlling for GA and BW, the durations, birth to FEF, and FEF to discharge/transfer remained significant ( P < .05). In a multivariable logistic regression analysis adjusting for GA, bronchopulmonary dysplasia, and surgical ligation for patent ductus arteriosus, the only independent risk factor of ROP was duration from FEF to discharge/transfer ( P < .05). Conclusions: Low weight velocity from day 7 to day 28 may be a useful predictor for the development of ROP but is dependent on GA and BW. A delay to reach FEF, which is associated with comorbidities of ROP, appears to be a risk factor for ROP that is independent of GA and BW. [ J Pediatr Ophthalmol Strabismus . 2019;56(3):168–172.]

BACKGROUND Upper gastrointestinal bleeding (UGIB) is one of the common life-threatening emergency hospital admissions. Upper GI Endoscopy is one of the common diagnostic examinations for identifying the cause of bleeding in our as well as in resourcelimited setup which ultimately help a clinician for “resource-sensitive approach”. METHODS This observational study (2015-2017) of upper gastrointestinal bleeding (UGIB) was performed at rural based multispecialty teaching hospital in consecutive 115 adult admitted patients (age>12 years) to find out aetiology and clinical as well as esophagogastroduodenoscopic profile. RESULTS Of 115 patients of UGIB, 75 were male (65.21%) and 40 female (34.78%). Mean age was 42.06 ±16.31. 77 (66.95%) presented with hematemesis, 21 (18.26%) with melena, 16 (13.91%) with hematemesis combined with melena and 1 patient presented with hematemesis as well as haematochezia. Endoscopy was able to detect definite cause of UGIB in 104 and in 11 patients it was normal (90.43%). Variceal bleed was commonest and was present in 48 patients, of whom 44 patients (38.26%) had oesophageal, 02 had gastric and other 2 had both oesophageal as well as gastric varices. In non-variceal bleeding, gastric and duodenal ulcer disease was present in 12, esophagitis in 10, oesophageal vascular ectasia in 02, erosive gastritis in 17, gastric malignancy in 04; Mallory Weiss tear in 06, erosive gastritis with duodenitis in 04, and esophagitis with gastric ulcer and duodenal ulcer in 01. 10 of 17 patients who had erosive gastritis gave history of NSAID use. Of the 48 patients who had variceal bleeding, 33 were due to cirrhosis of liver, and 15 were because of non-cirrhotic portal hypertension. Aetiology of 33 patients, who had hospital admission due to cirrhosis of liver related UGIB, was alcohol, hepatitis B, and hepatitis C in 29, 2 and 1 patients respectively. 81 (70.43%) had acute bleeding while 34 (29.56%) had recurrent bleeding. 17 patients were admitted in 2015, 45 in 2016 and 53 in 2017 for UGIB. There was no seasonal variation in incidence of UGIB. CONCLUSIONS Esophagogastroduodenoscopy is one of the very important diagnostic tools to find out aetiology of UGIB. This facility should be available widely at health centers of India which may help clinicians for better management of UGIB.

Glucagon-Like Peptide-1 (GLP-1) is an insulin secretagogue which is elevated after Roux-en-Y Gastric Bypass (RYGB). However, its contribution to glucose metabolism after RYGB remains uncertain. Aims We tested the hypothesis that GLP-1 lowers postprandial glucose concentrations and improves β-cell function after RYGB. Materials and Methods To address these questions we used a labeled mixed meal to assess glucose metabolism and islet function in 12 obese subjects with type 2 diabetes studied before and four weeks after RYGB. During the post-RYGB study subjects were randomly assigned to receive an infusion of either saline or Exendin-9,39 a competitive antagonist of GLP-1 at its receptor. Exendin-9,39 was infused at 300 pmol/kg/min for 6 h. All subjects underwent RYGB for medically-complicated obesity. Results Exendin-9,39 resulted in increased integrated incremental postprandial glucose concentrations (181 ± 154 vs. 582 ± 129 mmol per 6 h, p = 0.02). In contrast, this was unchanged in the presence of saline (275 ± 88 vs. 315 ± 66 mmol per 6 h, p = 0.56) after RYGB. Exendin-9,39 also impaired β-cell responsivity to glucose but did not alter Disposition Index (DI). Conclusions These data indicate that the elevated GLP-1 concentrations that occur early after RYGB improve postprandial glucose tolerance by enhancing postprandial insulin secretion.

In December 2019, an outbreak of viral pneumonia of unknown etiology arose in Wuhan, Hubei Province, China. Eventually isolated and named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), this virus has caused a global pandemic of the pneumonia-like Coronavirus Disease (COVID-19). With global infection rates and deaths mounting, the medical community has been forced to recognize, test, and treat these patients within a rapidly evolving situation and a shortage of resources. In this article, we summarize the most recent data pertaining to the clinical presentation, diagnostic tests, imaging, and management strategies for COVID-19. This article concludes with a discussion of ongoing efforts to develop critically needed therapeutics and vaccines, which may subsequently shape our responses to future pandemics.

Background & Aims Although HBV vaccine has a 95% seroconversion rate in the general population, patients with chronic liver disease have reduced seroconversion rates (16-79%). The aim of the study was to describe seroconversion rates with HBV vaccines in patients with chronic liver disease. Approach & Results Retrospective chart review was performed among 652 patients who received a complete HBV vaccine series in the hepatology clinic. Of those, 126 patients that were included, 111 received a single dose series, and 15 patients received a double dose series. The seroconversion rate was overall low at 35%, and stayed the same at 35% with double dose and at 33% with single dose. Patients who received a single dose series were further analyzed to review risk factors for seroconversion. Overall, 65% of patients had cirrhosis. Patients were more likely to seroconvert if no cirrhosis (51% vs 72%, P=.04), higher aminotransferase levels, intermediate anti-HBs (2.5-11.9 mIU/mL) at baseline (87.5% vs 14%) Conclusion Patients with chronic liver disease had a low rate (35%) of response to HBV vaccination. The response rates did not improve in patients that received double dose series. Patients with cirrhosis, lower aminotransferase levels and with a lower baseline anti-HBs had decreased response rates.

Importance People who inject drugs (PWID) who are being treated for infective endocarditis remain at risk of new bloodstream infections (BSIs) due to ongoing intravenous drug use (IVDU). Objectives To characterize new BSIs in PWID receiving treatment for infective endocarditis, to determine the clinical factors associated with their development, and to determine whether new BSIs and treatment setting are associated with mortality. Design, Setting, and Participants This retrospective cohort study was performed at 3 tertiary care hospitals in London, Ontario, Canada, from April 1, 2007, to March 31, 2018. Participants included a consecutive sample of all PWID 18 years or older admitted with infective endocarditis. Data were analyzed from April 1, 2007, to June 29, 2018. Main Outcomes and Measures New BSIs and factors associated with their development, treatment setting of infective endocarditis episodes (ie, inpatient vs outpatient), and 90-day mortality. Results The analysis identified 420 unique episodes of infective endocarditis in 309 PWID (mean [SD] patient age, 35.7 [9.7] years; 213 episodes [50.7%] involving male patients), with 82 (19.5%) complicated by new BSIs. There were 138 independent new BSIs, of which 68 (49.3%) were polymicrobial and 266 were unique isolates. Aerobic gram-negative bacilli (143 of 266 [53.8%]) andCandidaspecies (75 of 266 [28.2%]) were the most common microorganisms. Ongoing inpatient IVDU was documented by a physician in 194 infective endocarditis episodes (46.2%), and 127 of these (65.5%) were confirmed by urine toxicology results. Multivariable time-dependent Cox regression demonstrated that previous infective endocarditis (hazard ratio [HR], 1.89; 95% CI, 1.20-2.98), inpatient treatment (HR, 4.49; 95% CI, 2.30-8.76), and physician-documented inpatient IVDU (HR, 5.07; 95% CI, 2.68-9.60) were associated with a significantly higher rate of new BSIs, whereas inpatient addiction treatment was associated with a significantly lower rate (HR, 0.53; 95% CI, 0.32-0.88). New BSIs were not significantly associated with 90-day mortality (HR, 1.76; 95% CI, 0.78-4.02); significant factors associated with mortality included inpatient infective endocarditis treatment (HR, 3.39; 95% CI, 1.53-7.53), intensive care unit admission (HR, 9.51; 95% CI, 4.91-18.42), and methicillin-resistantStaphylococcus aureusinfective endocarditis (HR, 1.77; 95% CI, 1.03-3.03), whereas right-sided infective endocarditis was associated with a significantly lower mortality rate (HR, 0.41; 95% CI, 0.25-0.67). Conclusions and Relevance In this study, new BSIs were common in PWID receiving parenteral treatment for infective endocarditis. Discharging patients to outpatient treatment was not associated with an increase in new BSI incidence or mortality; carefully selected PWID may therefore be considered for such treatment.

Leukocytoclastic vasculitis (LCV) is a rare vascular inflammatory condition that affects post-capillary venules. Its incidence in the pediatric population is unknown. However, its incidence has been shown to increase with age. The causes of LCV can be varied, ranging from drugs to infections to systemic disease. LCV as a presenting symptom of inflammatory bowel disease (IBD) is rare, especially in the pediatric population. A 15-year-old female with a family history of systemic lupus erythematosus was transferred to our hospital with a month-long history of rash, joint swelling and tenderness, periorbital edema, weight loss, and diarrhea. She presented with the objective findings of a biopsy showing LCV and a computed tomography scan read that was concerning for IBD versus infectious colitis. She had a thorough workup, involving both the rheumatology and gastroenterology services, and was ultimately found to have Crohn’s disease. This case reveals the importance of recognition of a constellation of symptoms in IBD even when they are not classical in nature at initial presentation.

There is a lack of data describing the impact of the novel coronavirus 19 pandemic on the patients of chronic kidney disease stage V-dialysis (CKD V-D) from resource-limited countries. A growing body of literature describes an increased susceptibility of CKD V-D to COVID-19 with adverse outcomes in those with severe disease. In the current retrospective report, we elucidate the outcome in consecutive 37 CKD V-D patients with COVID-19 from two dialysis centres in Mumbai, India. Of the 37 patients included in the study, 56.7% of patients were asymptomatic or had mild disease and 27% presented with severe symptoms. The recovery rate was 63%, all those who presented with a severe disease succumbed to the infection. Thirty per cent of patients presented with an extended dialysis break due to various logistic and social issues. Though the overall clinical presentation and outcomes of this cohort from a limited resource setting mimic the global scenario, unique social and logistic issues are an additional burden to the patient, caregivers and the health-care facilities, which may worsen the outcomes in the future as the pandemic continues to spread.

As the prevalence of obesity has increased, bariatric surgery has become more common because of its proven efficacy at promoting weight loss and improving weight-related medical comorbidities. Although generally successful, bariatric surgery may also lead to complications and negatively affect health. This article highlights some common and rare complications of bariatric surgery. Specifically, it discusses the risk of nutrient deficiencies (which is influenced by surgery type) and their downstream effects, including ill-effects on bone health. Rarer complications, such as postbypass hypoglycemia and alcohol use disorder, are also discussed.

Taking a sexual history is an important facet of adolescent health that can be challenging for healthcare providers. Adolescents and young adults aged 13–24 are at increased risk for sexually transmitted infections (STIs) due to risky sexual behaviors. Many of these high-risk behaviors are influenced by related risk behaviors such as drug and alcohol intake, peer norms, and sexual health education (or lack thereof). The long-term consequences of STIs can include fertility problems and maternal-fetal transmission of infections, in addition to the obvious public health risks of continued transmission in the community. For these reasons, it is essential to take a thorough sexual history using the methods outlined below. Providers should aim to make the patient feel comfortable by reinforcing normalcy and maintaining confidentiality in their interaction. Finally, the physical exam is crucial in forming a differential diagnosis of any symptoms that a patient might be experiencing. This chapter will provide insight into methods of obtaining a sexual history from a patient in a professional, comfortable, and efficient manner.

The clinical constellation of signs and symptoms consistent with glucocorticoid excess is termed Cushing syndrome (CS). The most common etiology for CS is the administration of exogenous glucocorticoids. This chapter will focus on endogenous forms of overt cortisol excess. Patients with CS present with a spectrum of clinical manifestations ranging from metabolic abnormalities to classical features of CS. Clinical presentation depends on the severity and duration of cortisol excess, and individual susceptibility. CS presents with high morbidity and mortality, especially if unrecognized or diagnosis is delayed. This chapter will describe epidemiology, diagnostic workup, clinical presentation, and management of various types of endogenous CS.

Obesity and its related comorbidities make up a large part of healthcare expenditures. Despite a wide array of options for treatment of obesity, rates of sustained weight loss continue to be low, leading patients to seek alternative treatment options. Although the first medically utilized ketogenic diet was described nearly 100 years ago, it has made a resurgence as a treatment option for obesity. Despite increased popularity in the lay public and increased use of ketogenic dietary strategies for metabolic therapy, we are still beginning to unravel the metabolic impact of long-term dietary ketosis. There are a number of recent trials that have highlighted the short- and long-term benefits of ketogenic diet on weight, glycemic control, and other endocrine functions including reproductive hormones. This review is a summary of available data on the effectiveness and durability of the ketogenic diet when compared to conventional interventions. Ketogenic dietary strategies may play a role in short-term improvement of important metabolic parameters with potential for long-term benefit. However, response may vary due to inter-individual ability to maintain long-term carbohydrate restriction.