Clinical Case Registry Research Articles

The Symptomatic Expression in Chinese Patients with Suspected COVID-19 Omicron Variant Infection: A Clinical Case Registry Study

Little systematic research has been conducted into the symptomatic expression of COVID-19 infections in patients. It is known that symptomatic expression varies between patients, but the nature and extent of this variability is poorly understood. This paper elaborates on the symptoms reported by Chinese patients infected with COVID-19 during the Omicron wave, and compares this with available data from other countries. This was an observational clinical case registry study of Chinese patients with suspected Omicron variant COVID-19 infection. Symptoms were prospectively collected via a 171-item questionnaire and entered into the Clificol COVID-19 Clinical Case Registry. Two types of symptoms were distinguished: A) common clinical symptoms as identified by a search of available/published data, and B) homeopathic symptoms, used for the selection of the most suitable homeopathic medicine. Data were mainly analysed descriptively. Additionally, we compared the prevalence of the reported symptoms with available symptom data from the UK and France. Twenty one Chinese practitioners collected questionnaires on 388 cases that received a first homeopathic prescription between 5 December 2021 and 8 April 2022. With respect to A), the most frequently reported clinical symptoms were respectively cough (71%), fever (65%), extreme tiredness (58%), headache (51%), sore throat (46%), runny nose (34%), unusual muscle pains (31%), hoarseness (21%), eye soreness (8%) and brain fog (6%). With respect to B), homeopathic symptoms related to cough and fever were particularly prevalent. This study identified the reported symptoms of Chinese COVID-19 patients with suspected Omicron variant infection. A more detailed understanding of the clinical presentation of COVID-19 variants in different countries is important for the selection of test-triggering symptoms.

Homeopathic Treatment of COVID-19 Patients: Findings of the Clificol International Clinical Case Registry

Homeopathic Treatment of COVID-19 Patients: Findings of the Clificol International Clinical Case Registry

The Role of Lipids in Local Anaesthetic Intoxication (Intralipids in Short Supply)

Systemic toxicity of local anaesthetics (LA) is a rare but often serious event. The clinical cases reported in the literature show that its clinical expression can be very polymorphous. The use of a peripheral block with ultrasound guidance reduces the incidence of vascular puncture and systemic toxicity Systemic toxicity is often delayed after L A injection. Therefore, close monitoring during the first 30 minutes after ALR (especially with ultrasound guidance) seems recommended. In case of a systemic accident, the administration of an intravenous lipid emulsion ELI is now part of the recommendations to be followed in case of cardiorespiratory arrest induced by a systemic overdose of local anaesthetic. The mechanisms of ELI are complex and probably multiple. Their use should therefore not replace other means of resuscitation, but appears to be an effective additional element. Further experimental studies and a clinical case registry will probably make it possible to better characterise the effects of an ELI-AL combination and to better understand the elements which, today, maintain the controversy of their use.

1086. COVID-19 in a Comprehensive Cancer Center: 2020-2022

Abstract Background Patients with COVID-19 and underlying malignancies, particularly those receiving immunosuppressive therapy, are at higher risk of severe COVID-19 disease. Our retrospective cohort study examines the outcomes of COVID-19 infection in patients with different underlying malignancies admitted to a 710- beds comprehensive cancer center during the first 2 years of the pandemic. Methods All patients with cancer admitted to MD Anderson Cancer Center with a positive PCR test for SARS-CoV-2 were included in a clinical case registry from 3/22/20 (first hospitalized COVID-19 patient) to 3/31/22. This clinical registry was approved at the beginning of the COVID-19 pandemic by the Quality Improvement Assessment Board at MDACC. Clinical information including type of malignancy, date of admission, length of stay, need for invasive mechanical ventilation (IMV), and in-hospital mortality was obtained from their electronic medical records. Statistical analysis was performed using a two-proportion z-test where p< 0.05 was considered significant. Results A total of 1748 patients with cancer and COVID-19 infection were admitted over a 2-year period (3.2% of total hospital admissions during the same period), 49% had hematological malignancies (HM) (see table). Patients with HM had significantly higher readmission rates (17.3% vs 9.1%, p< 0.0001), IMV rates (7.8% vs 4.4%, p=0.0029), and inpatient mortality rates (13.6% vs 7.1%, p< 0.0001). compared to patients with solid tumors (ST). Total mortality rate was 8.8% (154 patients), even higher in patients with different types of HM, such as lymphoma 18.1%, AML 14.2%, MM 8.4%, CML 7.1% while the mortality for ST was 7.1%. COVID-19 Hospitalized Patients at UT-MDACC (3/22/20-3/31/22) UT-MDACC: The University of Texas MD Anderson Cancer Center *p-value <0.01 for z-test of 2 proportions (one-tailed) Conclusion HM patients hospitalized with COVID-19 infection had more severe disease and worse outcomes based on readmissions, IMV, and mortality rates. Preventive measures, prompt diagnosis and early treatments should be considered on this patient population. Disclosures Roy F. Chemaly, MD/MPH, Karius: Advisor/Consultant|Karius: Grant/Research Support.

Searching for the Genus Epidemicus in Chinese Patients: Findings from the Clificol COVID-19 Clinical Case Registry.

The Clificol COVID-19 Support Project is an innovative international data collection project aimed at tackling some of the core questions in homeopathy. This paper reports on the further investigation of the genus epidemicus concept during the first wave of the pandemic in the Chinese population. The design is an observational clinical case registry study of Chinese patients with confirmed or suspected coronavirus disease 2019 (COVID-19). The symptoms were prospectively collected via a 150-item questionnaire. The concept of genus epidemicus, including the role of treatment individualization, was investigated by analyzing whether presenting symptoms clustered into distinct groups. Two standard statistical analysis techniques were utilized: principal component analysis for extracting the most meaningful symptoms of the dataset; the k-means clustering algorithm for automatically assigning groups based on similarity between presenting symptoms. 20 Chinese practitioners collected 359 cases in the first half of 2020 (766 consultations, 363 prescriptions). The cluster analysis found two to be the optimum number of clusters. These two symptomatic clusters had a high overlap with the two most commonly prescribed remedies in these sub-populations: in cluster 1 there were 297 prescriptions, 95.6% of which were Gelsemium sempervirens; in cluster 2 there were 61 prescriptions, 95.1% of which were Bryonia alba. This is the first study to investigate the notion of genus epidemicus by using modern statistical techniques. These analyses identified at least two distinct symptom pictures. The notion of a single COVID-19 genus epidemicus did not apply in the studied population.

Treatment Patterns in Essential Tremor: A Retrospective Analysis.

Background:Although first line therapies for essential tremor have been identified from small clinical trials, responses are variable. We conducted a survey of tremor management in a large sample of ET cases.Methods:The Movement Disorders Clinical Case Registry within a US Veterans Health Administration medical center was used to identify 1468 patients with ET.Results:Of 1468 charts reviewed, 1074 (73.19%) met criteria for ET with characterization of temporal course and treatment; 291/1074 subjects (27.1%) did not receive any treatment. Almost half (500/1074; 46.6%) of the patients received monotherapy, 196/1074 (18.2%) two, 66/1074 (6.1%) three, and 21/1074 (2.0%) four or more medications. Of all prescriptions, primidone was the most used (546/1172; 46.6%), followed by propranolol (419; 35.8%), topiramate (122; 10.4%) and gabapentin (35; 3.0%). Medication response was available for a total of 1030 prescriptions, of which 138 (13.4%) were discontinued due to side effects; 180 (17.5%) prescriptions were ineffective. Furthermore, 52/1074 patients (4.8%) were treated with botulinum toxin injections and 41/1074 (3.8%) underwent deep brain stimulation surgery.Discussion:Our data suggest that more widespread recognition of limitations underlying conventional approaches, as well as increased referrals for nonpharmacological therapies, may be necessary to achieve improved outcomes in ET populations.

Outcomes using direct-acting antiviral hepatitis-C treatment in older versus younger Veterans.

Historically, older adults have been excluded from trials evaluating hepatitis C virus (HCV) treatment, in part, due to the adverse effects associated with previous regimens. Veterans are at high risk of HCV infection. Ledipasvir/sofosbuvir (LED/SOF) is a once daily antiviral regimen with demonstrated efficacy and tolerability among the younger population. We examined the tolerability and effectiveness of LED/SOF in Veterans age ≥65 years versus those <65 years who were treated at the Atlanta VA Health Care System (AVAHCS). Using the VA Clinical Case Registry, all persons who filled a LED/SOF prescription at the AVAHCS from January 1, 2015, through March 31, 2016, were identified. The electronic medical records were reviewed to identify basic demographic information: comorbidities; polypharmacy; and outcomes. Sustained virologic response (SVR) was defined as an undetectable HCV RNA, at least 12 weeks after completing treatment. Descriptive statistics were employed using SAS v9.2. We identified 345 Veterans who filled LED/SOF during the study period; 94 were excluded due to exposure to ribavirin and IFN containing regimens; 97 (38.6%) were ≥65 years. Veterans were predominantly black (57%) and male (97%). Cancer was more prevalent among older Veterans (p=0.047) as was polypharmacy (p=0.001). Treatment completion rates between older and younger Veterans were not significantly different (99 vs. 95%, respectively; p=0.16), but significantly more older Veterans achieved SVR (98 vs. 91%; p=0.03). LED/SOF was a well-tolerated and effective regimen in an older Veteran population despite their multiple comorbidities and polypharmacy presence.

Association between human immunodeficiency virus serostatus and the prevalence of atrial fibrillation.

Atrial fibrillation (AF) leads to increased risk for stroke. Human immunodeficiency virus (HIV) is associated with cardiovascular disease (CVD), although it is unclear if HIV is associated with AF. The purpose of this study was to evaluate the association between HIV serostatus and the prevalence of AF in the Multicenter AIDS Cohort Study.A cross sectional study was conducted among 1674 HIV-infected (HIV+) and uninfected (HIV–) men who completed resting 12-lead electrocardiograms, and/or ambulatory electrocardiogram monitoring. Multivariable logistic regression was used to evaluate the association between AF, defined as the presence of either AF or atrial flutter, and HIV+ serostatus. Associations were adjusted for demographic variables, and then also for CVD risk factors.HIV+ men were younger than HIV– men (median 55.5 vs 61.7 years, P < .001) and were more frequently African-American (30.5% vs 17.8%, P < .001). Most HIV+ men (81%) had undetectable viral load. The age and race adjusted prevalence of AF was 3.0% in HIV+ and 3.3% in HIV– men. There was only 1 case of AF among African-American men. There were no associations between AF and HIV serostatus after adjusting for demographic factors (odds ratio 0.76; 95% CI 0.37 to –1.58; P = .47) or after further adjustment for CVD risk factors (odds ratio 0.84; 95% CI 0.39 to –1.81; P = .66).We found no association between HIV and AF in this cohort in which viral replication among the HIV+ men is generally suppressed. The overall prevalence of AF was low and was rare in African-American men.

HCV Elimination in the US Department of Veterans Affairs.

HCV Elimination in the US Department of Veterans Affairs.

1009. Dolutegravir and Doravirine in Combination: When Standard Antiretroviral Regimens are Unacceptable

BackgroundA drug-drug interaction study between dolutegravir and doravirine in healthy volunteers found no evidence of untoward interaction. Whilst we hypothesize that the combination would be safe and effective, there is no supportive clinical data. We aimed to assess the rationale for use of dolutegravir and doravirine in combination and clinical outcomes among persons with HIV infection (PWH) receiving care at the Washington DC VAMC.MethodsA quality improvement initiative utilized the clinical case registry to identify all PWH receiving both dolutegravir and doravirine. We conducted chart review to examine (a) the reasons for switch from other ART to dolutegravir and doravirine, and comorbidities, HIV resistance mutations or drug interactions precluding the use of standard ART, (b) adverse events or side effects and (c) achievement of virologic suppression.ResultsA case registry search revealed 21 individuals receiving combination dolutegravir doravirine from 2018–2020 (Table 1 and Figure 1). Side effects were not noted except one patient developed mild diarrhea that improved with continuation of therapy. Four patients were hospitalized during the follow-up period for reasons unrelated to the medications. One patient who was admitted to the ICU with shock and multi-organ failure was switched on admission but died four days later and therefore was not included in the analysis of viral outcome (Table 2). One patient had cardiac arrest following missed dialysis, hyperkalemia and rectal hemorrhage from metastatic rectal cancer.Table 1: Patient Demographics. Figure 1: Reasons for Switching to Dolutegravir with Doravirine. Table 2: Virologic Control Before and After Switching to Dolutegravir with Doravirine. ConclusionIn an era of abundant ART options, we identified a subset of older PWH whose treatment options are defined by extensive comorbidities, viral resistance, and medication interactions or toxicities. Doravirine is attractive for this population as it can be used in renal impairment, moderate hepatic impairment, is unaffected by timing of meals, and (unlike rilpivirine) has no interaction with proton pump inhibitors. Dolutegravir is included in NRTI-sparing regimens that HHS guidelines suggest should be considered in older PWH, especially with CKD. We found that dolutegravir with doravirine is well tolerated, and achieves virologic suppression in the majority of PWH, indicating this combination is useful when other ART options cannot be used.Disclosures All Authors: No reported disclosures

Hepatitis C Care Continuum in a Human Immunodeficiency Virus (HIV) Positive Cohort: Data From the HIV Atlanta Veterans Affairs Cohort Study.

BackgroundHuman immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection is associated with accelerated progression to cirrhosis, end-stage liver disease, and liver-associated death. It is fortunate that curative direct-acting antivirals for the treatment of HCV are widely available in the VA healthcare system. We attempted to identify, evaluate, and treat all HIV/HCV-coinfected persons at the Atlanta VA Healthcare System.MethodsHuman immunodeficiency virus/HCV-coinfected persons at Atlanta VA between 2015 and 2018 were identified using the HIV Atlanta Veterans Affairs Cohort Study and Hepatitis C VA Clinical Case Registry. Retrospective reviews of each electronic medical record were conducted by the hepatitis C clinical team for validation. The primary end point was achieving sustained virologic response.ResultsOne hundred thirty-eight veterans with HIV and hepatitis C viremia were identified. One hundred twenty-five (90%) were evaluated for treatment and 113 (91%) were initiated on direct-acting antiviral therapy. Median age at initiation of treatment was 60 years and the majority were black race (90%). Genotype 1a was most common (70%) and 41% had compensated cirrhosis. One hundred eight completed treatment and 96% achieved sustained virologic response. Six veterans had virologic relapse; 4 had treatment-emergent resistance mutations in the NS5a gene. Mean CD4 was 580 cells/mm3 with HIV viral suppression in 82% of the cohort. In those not treated, unstable housing (25%), active substance use (31%), and psychiatric conditions (42%) were identified barriers to care.ConclusionsThrough a concerted, systematic effort, over 80% of HIV/hepatitis C persons in the Atlanta VA have been initiated on treatment for hepatitis C, 96% of which have been cured.

Validation of HIV-infected cohort identification using automated clinical data in the Department of Veterans Affairs.

The US Department of Veterans Affairs (VA) is the largest integrated health care provider for HIV-infected patients in the USA. VA data for HIV-specific clinical and quality improvement research are an important resource. We sought to determine the accuracy of using the VA Corporate Data Warehouse (CDW), a fully automated medical records database for all VA users nationally, to identify HIV-infected patients compared with a gold-standard VA HIV Clinical Case Registry (CCR). We assessed the test performance characteristics of each of our CDW criteria-based algorithms (presence of one, two or all of the following: diagnostic codes for HIV, positive HIV laboratory tests, and prescription for HIV medication) by calculating their sensitivity (proportion of HIV-positive patients in the CCR accurately detected as HIV-positive by the CDW algorithm) and positive predictive value (PPV; the proportion of patients identified by the CDW algorithm who were classified as HIV-positive from the CCR). We found that using a CDW algorithm requiring two of three HIV diagnostic criteria yielded the highest sensitivity (95.2%) with very little trade-off in PPV (93.5%). A two diagnostic criteria-based algorithm can be utilized to accurately identify HIV-infected cohorts seen in the nationwide VA health care system.

Real-world effectiveness of sofosbuvir/velpatasvir/voxilaprevir in 573 direct-acting antiviral experienced hepatitis C patients.

Sofosbuvir/velpatasvir/voxilaprevir (SOF/VEL/VOX) provides a needed hepatitis C virus (HCV) antiviral option for direct-acting antiviral (DAA)-experienced patients. We evaluated the effectiveness of SOF/VEL/VOX for 12weeks in DAA-experienced patients with genotype 1-4 treated in clinical practice. In this observational cohort analysis from the Veterans Affairs' Clinical Case Registry, 573 DAA-experienced patients initiating SOF/VEL/VOX were included: 490 genotype 1, 20 genotype 2, 51 genotype 3 and 12 genotype 4. Rates of cirrhosis were 32.7%, 30.0%, 49.0% and 58.3%; rates of prior NS5A-experience were 100.0%, 95.0%, 90.2% and 100.0% for genotypes 1-4, respectively. Overall SVR rates were 90.7% (429/473), 90.0% (18/20), 91.3% (42/46) and 100.0% (12/12) for genotypes 1-4, respectively, and were 91.3% (274/300), 88.9% (16/18), 90.2% (37/41) and 100.0% (11/11) for those with prior NS5A+NS5B experience. For genotype 1, SVR rates were similar in patients with prior regimens of ledipasvir/SOF (90.6%, 298/329), elbasvir/grazoprevir (91.2%, 73/80) and ombitasvir/paritaprevir/ritonavir/dasabuvir (90.9%, 70/77). SVR rates in genotype 1, 2 and 3 patients with prior SOF/VEL experience were 78.9% (15/19), 86.7% (13/15) and 84.6% (11/13). In genotype 1-4 patients completing 12weeks of SOF/VEL/VOX, overall SVR rates were 95.1% (409/430), 89.5% (17/19), 93.3% (42/45) and 100% (12/12). In this diverse real-world cohort of heavily NS5A pretreated patients, SOF/VEL/VOX SVR rates in DAA-experienced patients were high across all genotypes. Genotype 1 patients who had prior experience with the most commonly prescribed NS5A regimens achieved similarly high SVR rates when retreated with SOF/VEL/VOX. For genotypes 1, 2 and 3, patients with prior SOF/VEL experience had lower SVR rates.

LO46: Lost to follow-up post-sexual and domestic assault: An evaluation of prevalence and correlates of cases presenting to the emergency department

Introduction: Domestic violence (DV) and sexual assault (SA), together called sexual and gender-based violence (SGBV), are traumatic and life-changing events. Post-assault follow-up care is essential for survivor recovery through medical care, mental health functioning, and injury reassessment. The objective of this analysis was to determine the frequency of loss to follow-up (LTFU) in a SGBV population, and the characteristics most commonly associated with LTFU. Methods: The Sexual Assault and Partner Abuse Care Program (SAPACP) is the only Ottawa program for emergency/forensic care. Demographic and assault characteristics were abstracted from the SAPACP clinical case registry (1 Jan 2015 to 20 Dec 2017). Descriptive analyses and bivariable/multivariable logistic regression modelling assessed factors most strongly associated with LTFU using odds ratios (OR), adjusted OR (AOR), and 95% confidence intervals (CI). Results: Among 894 initial SAPACP visits, 482 (53.9%) were LTFU. Of those LTFU, 445 (92.3%) were female, 185 (38.4%) arrived by ambulance, 284 presented acutely (58.9%), 70 (14.5%) had substance use issues, and 82 (17.0%) were re-victimized. There were 229 (47.5%) sexual assaults, 201 (41.7%) physical assaults, and 92 (19.1%) verbal assaults. LTFU patients were more likely to arrive by ambulance (AOR: 1.09, 95% CI: 1.34-2.69), experience re-victimization (AOR: 1.94, 95% CI: 1.25-3.03), and have a substance use disorder (AOR: 1.67, 95% CI:1.02-2.73). Those more likely to attend follow-up included sexual assault survivors (AOR: 0.37, 95% CI: 0.27-0.50) and acute presenters (AOR: 0.58, 95% CI: 0.44-0.78). Conclusion: Over half of patients arriving for initial SAPACP visits did not follow-up. LTFU was more likely among cases that arrived by ambulance, and those involving revicitimization or substance use disorders. Follow-up is critical for maintaining mental and physical health post-trauma. While some characteristics increased follow-up likelihood, this study has identified groups that need attention to reduce LTFU.

Risk of suicide and accidental deaths among elderly patients with cognitive impairment

BackgroundThe leading causes of death among the elderly with cognitive impairment are unknown. This study aims to estimate the suicide and accidental death rates on the basis of a clinical case registry of patients diagnosed with cognitive impairment.MethodsThe target sample consisted of 10,169 patients diagnosed with dementia or mild cognitive impairment (MCI), who were evaluated at the Clinical Research Center for Dementia of Korea (CREDOS) from January 2005 to December 2013. Information about whether the patients had died from suicide or in any kind of accident by December 31, 2016, was obtained from the database of the National Statistical Office (NSO). The standardized mortality ratio (SMR) and Cox-regression analysis were performed for evaluating the risk of suicide and accidental death as identified by the ICD-10.ResultsThe average of the Clinical Dementia Rating Scale (CDR) score (0.68 vs 0.93) was lower, and the age at the time of study registration (71.42 vs 75.68 years) was younger in the suicidal death group, as compared to the accidental death group. The overall SMR for accidental death in cognitively impaired patients (1.44, 95% CI 1.22–1.71) was significantly higher than the general population. Later onset (1.43, 95% CI 1.20–1.71) and older age (2.21, 95% CI 1.04–4.68) increased the risk of accidental death in cognitively impaired patients. According to the dementia subtypes, the SMR for accidental death was higher in both Alzheimer’s disease (1.72, 95% CI 1.36–2.14) and vascular dementia (2.14, 95% CI 1.27–3.38). Additionally, the SMR for accidental death showed an increasing tendency as the CDR score increased (mild 1.80, 95% CI 1.32–2.42, moderate 1.86, 95% CI 1.07–3.03, severe 3.32, 95% CI 1.08–7.76). Unemployment increased the risks of both suicide (3.71, 95% CI 1.54–8.95) and accidental death (2.09, 95% CI 1.20–3.63).ConclusionsAmong people with cognitive impairment, the risk of death by suicide did not increase, whereas that of accidental death increased significantly. Preventive strategies for premature mortality in those with cognitive impairment should be implemented from the early stages and should include careful evaluation of the individual risk factors for each type of death.

Direct-acting antiviral sustained virologic response: Impact on mortality in patients without advanced liver disease.

Successfully treating hepatitis C virus with DAAs in patients without clinically apparent advanced liver disease translates into a significant mortality benefit. (Hepatology 2018).

Evaluating screening approaches for hepatocellular carcinoma in a cohort of HCV related cirrhosis patients from the Veteran\u2019s Affairs Health Care System

BackgroundHepatocellular carcinoma (HCC) has limited treatment options in patients with advanced stage disease and early detection of HCC through surveillance programs is a key component towards reducing mortality. The current practice guidelines recommend that high-risk cirrhosis patients are screened every six months with ultrasonography but these are done in local hospitals with variable quality leading to disagreement about the benefit of HCC surveillance. The well-established diagnostic biomarker α-Fetoprotein (AFP) is used widely in screening but the reported performance varies widely across studies. We evaluate two biomarker screening approaches, a six-month risk prediction model and a parametric empirical Bayes (PEB) algorithm, in terms of their ability to improve the likelihood of early detection of HCC compared to current AFP alone when applied prospectively in a future study.MethodsWe used electronic medical records from the Department of Veterans Affairs Hepatitis C Clinical Case Registry to construct our analysis cohort, which consists of serial AFP tests in 11,222 cirrhosis control patients and 902 HCC cases prior to their HCC diagnosis. The six-month risk prediction model incorporates routinely measured laboratory tests, age, the rate of change in AFP over the past year with the current AFP. The PEB algorithm incorporates prior AFP screening values to identify patients with a significant elevated level of AFP at their current screen. We split the analysis cohort into independent training and validation datasets. All model fitting and parameter estimation was performed using the training data and the algorithm performance was assessed by applying each approach to patients in the validation dataset.ResultsWhen the screening-level false positive rate was set at 10%, the patient-level true positive rate using current AFP alone was 53.88% while the patient-level true positive rate for the six-month risk prediction model was 58.09% (4.21% increase) and PEB approach was 63.64% (9.76% increase). Both screening approaches identify a greater proportion of HCC cases earlier than using AFP alone.ConclusionsThe two approaches show greater potential to improve early detection of HCC compared to using the current AFP only and are worthy of further study.

CHA2DS2-VASc Score, Warfarin Use, and Risk for Thromboembolic Events Among HIV-Infected Persons With Atrial Fibrillation.

The prevalence of atrial fibrillation in the HIV-infected population is growing, but the ability of the CHA2DS2-VASc score to predict thromboembolic (TE) risk is unknown in this population. Within the Veterans Affairs HIV Clinical Case Registry, 914 patients had an atrial fibrillation diagnosis between 1997 and 2011 and no previous TE events. We compared TE incidence by CHA2DS2-VASc scores and stratified by warfarin use. Using Cox proportional hazards regression with adjustment for competing risks, we modeled associations of CHA2DS2-VASc scores and warfarin use with TE risk. At baseline, the distribution of CHA2DS2-VASc scores was 0 (n = 208), 1 (n = 285), and 2+ (n = 421); 34 patients developed 38 TE events during a median of 3.8 years follow-up. Event rates by CHA2DS2-VASc scores of 0, 1, and 2+ were 5.4, 9.3, and 8.1 per 1000 person years, respectively; multivariate-adjusted hazards ratios (HRs) were 1.70 (95% confidence interval: 0.65 to 4.45) for CHA2DS2-VASc score 1 (P = 0.28) and HR = 1.34 (0.51, 3.48) for score 2+ versus 0 (P = 0.55). Baseline warfarin use was associated with increased TE risk, although not statistically significant [HR 2.06 (0.86, 4.93), P = 0.11] with similar results when modeled as time-updated use and duration of use. In this national registry of HIV-infected veterans with atrial fibrillation, CHA2DS2-VASc scores were only weakly associated with TE risk. Furthermore, warfarin did not seem to be effective at preventing TE events. These results should raise concerns about the optimal strategy for TE prevention among HIV-infected persons with atrial fibrillation.

The effect of sustained virological response on the risk of extrahepatic manifestations of hepatitis C virus infection

Background and aimChronic HCV infection is associated with several extrahepatic manifestations (EHMs). Data on the effect of sustained virological response (SVR) on the risk of EHMs are limited.MethodsWe conducted a...

Risk factors for oropharynx cancer in a cohort of HIV-infected veterans

ObjectiveTo evaluate HIV-related and other clinical risk factors associated with oropharynx cancer (OPSCC) in HIV-infected U.S. Veterans. MethodsRetrospective cohort study utilizing Veterans Affairs HIV Clinical Case Registry (CCR) data from 1985 to 2010. Outcome was incident OPSCC as indicated by 1 inpatient or 2 outpatient ICD-9 codes. Cox proportional hazard models were used to determine hazard ratios (HR) and 95% confidence intervals (CI) for each risk factor on the time to OPSCC diagnosis. ResultsA total of 40,996 HIV-infected male veterans were included in the cohort with 97 cases of OPSCC. The age adjusted incidence rate was 23.2/100,000 [95% CI 17.8–29.2]. Age>50 (aHR=3.8, 95% CI 1.9–7.8), recent CD4<200 (aHR=3.8, 95% CI 2.0–7.3), and undetectable HIV viral loads 40–79% of the time (aHR=1.8, 95% CI 1.1–3.0) were associated with an increased risk of OPSCC. Era of HIV diagnosis, utilization of cART, nadir CD4 count, race, smoking history, and previous risk of HPV disease, including condyloma or invasive squamous cell carcinoma of the anus (SCCA) were not associated with increased risk of OPSCC. ConclusionPatients who were older at beginning of follow up, had lower CD4 counts around the time of OPSCC diagnosis, and moderate HIV viral control during follow-up had an increased risk of OPSCC. Other HPV-related diseases such as SCCA and condyloma did not increase the risk for OPSCC.