Division Of Infectious Diseases Research Articles

Retrospective study of a pilot program focused on educating dental patients on human papillomavirus and vaccination in a hospital setting.

Human papillomavirus (HPV) is an epidemic currently affecting 80 million people in the United States. The HPV virus can be passed from one person to another via sexual intercourse, oral sex, open mouth kissing and skin-to-skin contact. In some cases, the infection is not eliminated by the immune system and can cause cancer of the head and neck, cervix, anus, and genitals. There has been a rise in oropharyngeal cancer (OPC) associated with HPV, which can be missed on conventional dental screening examinations. Dentists should engage in promoting HPV vaccination as a primary measure for OPC prevention. The goal of this HPV pilot program was to educate and offer same day HPV vaccination to dental patients by using a multidisciplinary approach in a hospital setting. Patients 18 through 26 years of age who presented to the Erie County Medical Center's dental clinic were approached and educated on HPV. Eligible patients received a direct recommendation for the HPV vaccine. Those interested in same day vaccination were referred to the division of infectious diseases' YOU Center for Wellness. A retrospective chart review was completed for patients who were HPV educated from March 5, 2020, through December 15, 2021. Charts were evaluated for age, sex, race, ethnicity, reason for visit, HPV vaccine referral, and HPV vaccine administration. 326 patients were included in the chart review. The prominent sex, race, and ethnicity were male, Black or African American, and non-Hispanic origin. The median age was 23. Most patients presented to the dental clinic for an emergency visit and were not previously vaccinated against HPV. 110 patients were unvaccinated, and 44 patients were referred to the division of infectious disease for same day vaccination. Of these 44, 24 patients initiated the vaccination process. Five patients received all three doses, three patients received two doses, and 16 patients received one dose. This pilot program successfully vaccinated 24 patients with at least a single dose of the HPV vaccine. This multidisciplinary model can be implemented in other health care settings.

Long-term Effects of COVID-19 on Vascular Parameters—A Prospective Longitudinal Ultrasound Clinical Study

Objective: To investigate the longitudinal effects of COVID-19 on major vascular structures and parameters and clinical outcomes. Design: Observational prospective trial. Setting: Post-COVID-19 research clinic established by University of Louisville Division of Infectious Diseases. Participants: The study population consisted of 72 post-COVID-19 individuals and 11 non-COVID-19 infected participants in the control group. The participants were recruited from adult hospitals and from the community. The enrollment started in October 2020 and follow-up periods were at 3, 6, and 12 months from their initial COVID-19 diagnosis. Interventions: The participants were interviewed for medical and COVID-19 infection history. Samples of white blood cell (WBC), C-reactive protein (CRP), and D-dimer were taken at each visit. Certified sonographers performed vascular ultrasound on the study participants. Measurements and Main Results: Median intima-media thickness (IMT) was increased in mild/asymptomatic (0.80 mm) and severe/critical (0.90 mm) groups when compared with controls (0.60 mm; P < .001 for both groups). In the asymptomatic/mild group, 6-month median IMT (0.88 mm) was increased, compared with the 3-month group (0.75 mm), with P = .026. Increased age was associated with decreased mean arterial blood velocities (cm/s): common carotid ( r = −0.236, P = .032), internal carotid ( r = −0.208, P = .048), and subclavian artery mean velocity ( r = −0.357, P = .003). We did not find any instance of deep vein thrombosis. Median D-dimer, CRP, and WBC in the control group differed from asymptomatic/mild COVID-19 group ( P = .026, .011, and .003, respectively). Moreover, WBC in the asymptomatic/mild group and moderate COVID-19 group differed from severe/critical group ( P = .025 and P = .027, respectively); CRP also differed between asymptomatic/mild group and severe/critical group ( P = .014). Conclusions: There were differences in intima-media lumen thickness (IMT), arterial velocities, and inflammatory markers in post-COVID-19 patients. There was no instance of deep vein thrombosis in this post-COVID-19 study cohort. The increased IMT might infer atherosclerosis, which has shown to increase cardiovascular risks. It is not yet known whether the increase in IMT due to COVID should be treated in the same way as non-COVID-19 atherosclerosis—through statins, for example—or whether regular cardiovascular risk reduction would be useful. Clinical trial and mechanistic studies should be performed to further our understanding of COVID-19-related vascular pathologies.

Judge rules against former employee

Case name: Haynie v. Washington University School of Medicine Division of Infectious Diseases, No. 4:22CV672 (E.D. Mo. 10/18/23).

Safety and immunogenicity of a purified inactivated Zika virus vaccine candidate in adults primed with a Japanese encephalitis virus or yellow fever virus vaccine in the USA: a phase 1, randomised, double-blind, placebo-controlled clinical trial

Zika virus infection is a threat to at-risk populations, causing major birth defects and serious neurological complications. Development of a safe and efficacious Zika virus vaccine is, therefore, a global health priority. Assessment of heterologous flavivirus vaccination is important given co-circulation of Japanese encephalitis virus and yellow fever virus with Zika virus. We investigated the effect of priming flavivirus naive participants with a licensed flavivirus vaccine on the safety and immunogenicity of a purified inactivated Zika vaccine (ZPIV). This phase 1, placebo-controlled, double-blind trial was done at the Walter Reed Army Institute of Research Clinical Trials Center in Silver Spring, MD, USA. Eligible participants were healthy adults aged 18-49 years, with no detectable evidence of previous flavivirus exposure (by infection or vaccination), as measured by a microneutralisation assay. Individuals with serological evidence of HIV, hepatitis B, or hepatitis C infection were excluded, as were pregnant or breastfeeding women. Participants were recruited sequentially into one of three groups (1:1:1) to receive no primer, two doses of intramuscular Japanese encephalitis virus vaccine (IXIARO), or a single dose of subcutaneous yellow fever virus vaccine (YF-VAX). Within each group, participants were randomly assigned (4:1) to receive intramuscular ZPIV or placebo. Priming vaccinations were given 72-96 days before ZPIV. ZPIV was administered either two or three times, at days 0, 28, and 196-234. The primary outcome was occurrence of solicited systemic and local adverse events along with serious adverse events and adverse events of special interest. These data were analysed in all participants receiving at least one dose of ZPIV or placebo. Secondary outcomes included measurement of neutralizing antibody responses following ZPIV vaccination in all volunteers with available post-vaccination data. This trial is registered at ClinicalTrials.gov, NCT02963909. Between Nov 7, 2016, and Oct 30, 2018, 134 participants were assessed for eligibility. 21 did not meet inclusion criteria, 29 met exclusion criteria, and ten declined to participate. 75 participants were recruited and randomly assigned. 35 (47%) of 75 participants were male and 40 (53%) were female. 25 (33%) of 75 participants identified as Black or African American and 42 (56%) identified as White. These proportions and other baseline characteristics were similar between groups. There were no statistically significant differences in age, gender, race, or BMI between those who did and did not opt into the third dose. All participants received the planned priming IXIARO and YF-VAX vaccinations, but one participant who received YF-VAX dropped out before receipt of the first dose of ZPIV. 50 participants received a third dose of ZPIV or placebo, including 14 flavivirus-naive people, 17 people primed with Japanese encephalitis virus vaccine, and 19 participants primed with yellow fever vaccine. Vaccinations were well tolerated across groups. Pain at the injection site was the only adverse event reported more frequently in participants who received ZPIV than in those who received placebo (39 [65%] of 60 participants, 95% CI 51·6-76·9 who received ZPIV vs three [21·4%] of 14 who received placebo; 4·7-50·8; p=0·006). No patients had an adverse event of special interest or serious adverse event related to study treatment. At day 57, the flavivirus-naive volunteers had an 88% (63·6-98·5, 15 of 17) seroconversion rate (neutralising antibody titre ≥1:10) and geometric mean neutralising antibody titre (GMT) against Zika virus of 100·8 (39·7-255·7). In the Japanese encephalitis vaccine-primed group, the day 57 seroconversion rate was 31·6% (95% CI 12·6-56·6, six of 19) and GMT was 11·8 (6·1-22·8). Participants primed with YF-VAX had a seroconversion rate of 25% (95% CI 8·7-49·1, five of 20) and GMT of 6·6 (5·2-8·4). Humoral immune responses rose substantially following a third dose of ZPIV, with seroconversion rates of 100% (69·2-100; ten of ten), 92·9% (66·1-99·8; 13 of 14), and 60% (32·2-83·7, nine of 15) and GMTs of 511·5 (177·6-1473·6), 174·2 (51·6-587·6), and 79 (19·0-326·8) in the flavivirus naive, Japanese encephalitis vaccine-primed, and yellow fever vaccine-primed groups, respectively. We found ZPIV to be well tolerated in flavivirus naive and primed adults but that immunogenicity varied significantly according to antecedent flavivirus vaccination status. Immune bias towards the flavivirus antigen of initial exposure and the timing of vaccination may have impacted responses. A third ZPIV dose overcame much, but not all, of the discrepancy in immunogenicity. The results of this phase 1 clinical trial have implications for further evaluation of ZPIV's immunisation schedule and use of concomitant vaccinations. Department of Defense, Defense Health Agency; National Institute of Allergy and Infectious Diseases; and Division of Microbiology and Infectious Disease.

Bleeding Rectal Ulcer in an Elderly Veteran Receiving Pembrolizumab Therapy for Lung Cancer

From the ∗Stony Brook University Hospital, Stony Brook †Division of Infectious Disease, Northport Veteran Affairs, Northport, NY. Correspondence to: Alexander Njoroge, MD, Stony Brook University Hospital, 100 Nicolls Rd, Stony Brook, NY 11794. E-mail: [email protected]. The authors have no funding or conflicts of interest to disclose.

COVID-19 Is No Longer a Public Health Emergency: Implications for Patients and Clinicians

COVID-19 Is No Longer a Public Health Emergency: Implications for Patients and Clinicians

The Joys of Research and Mentorship - Personal Observations over Six Decades.

Journal Article Accepted manuscript The Joys of Research and Mentorship – Personal Observations over Six Decades Get access Martin S Hirsch, M.D Martin S Hirsch, M.D Infectious Disease Division, Massachusetts General Hospital, Massachusetts General HospitalInfectious Disease Division, 65 Landsdowne Street, Room 419, Cambridge, MA, US Corresponding author Email: mshirsch@partners.org Search for other works by this author on: Oxford Academic PubMed Google Scholar The Journal of Infectious Diseases, jiad139, https://doi.org/10.1093/infdis/jiad139 Published: 05 May 2023 Article history Received: 03 May 2023 Accepted: 03 May 2023 Published: 05 May 2023

Updating the diagnostic criteria for infective endocarditis: time for a (valve) replacement.

Journal Article Corrected proof Updating the Diagnostic Criteria for Infective Endocarditis: Time for a (Valve) Replacement Get access Molly L Paras Molly L Paras Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA Correspondence: M. L. Paras, Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit St, Bulfinch Suite 130, Boston, MA 02114, USA (mparas@mgh.harvard.edu). Search for other works by this author on: Oxford Academic PubMed Google Scholar Clinical Infectious Diseases, ciad269, https://doi.org/10.1093/cid/ciad269 Published: 04 May 2023 Article history Received: 12 April 2023 Editorial decision: 20 April 2023 Accepted: 03 May 2023 Published: 04 May 2023 Corrected and typeset: 01 June 2023

The intertwined epidemics of HIV and COVID-19 - emerging data and responses.

aDivision of HIV, Infectious Diseases, and Global Medicine; Department of Medicine; University of California, San Francisco (UCSF), USA bIII Division of Infectious Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Luigi Sacco University Hospital, University of Milan, Italy Correspondence to Agostino Riva, and Monica Gandhi, MD, Universita degli Studi di Milano, Milano, Italy. E-mail: [email protected]; [email protected]

The power of the gut in critical care.

Center for Experimental and Molecular Medicine and Department of Medicine, Division of Infectious Diseases and Amsterdam Institute for Infection and Immunity (AII), Amsterdam University Medical Centers (Amsterdam UMC), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Correspondence to W. Joost Wiersinga, MD, PhD, MBA, Division of Infectious Diseases and Center for Experimental and Molecular Medicine, Amsterdam UMC, AMC, Meibergdreef 9, Room G2-130, 1105 AZ Amsterdam, The Netherlands. Tel: +31 20 5669111; e-mail: [email protected]

Distinct inflammatory profiles linked to cardiovascular disease risk in HIV infection: implications for the design of preventive and therapeutic interventions.

aDivision of Hematology & Medical Oncology, Department of Medicine, Weill Cornell Medical College, New York, NY bDivision of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA. Correspondence to Jeffrey Laurence, MD, Division of Hematology & Medical Oncology, Weill Cornell Medical College, New York, NY 10065, USA. E-mail: [email protected] or Dean L. Winslow, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA 84305, USA. E-mail: [email protected] Received 16 December, 2022 Accepted 26 December, 2022

Clinical prediction rule for identifying older patients with toxigenic clostridioides difficile at the time of hospital admission

BackgroundThis study aimed to develop and validate a clinical prediction rule to screen older patients at risk of being toxigenic Clostridioides difficile carriers at the time of hospital admission.MethodsThis retrospective case-control study was performed at a university-affiliated hospital. Active surveillance using a real-time polymerase chain reaction (PCR) assay for the toxin genes of C. difficile was conducted among older patients (≥ 65 years) upon admission to the Division of Infectious Diseases of our institution. This rule was drawn from a derivative cohort between October 2019 and April 2021 using a multivariable logistic regression model. Clinical predictability was evaluated in the validation cohort between May 2021 and October 2021.ResultsOf 628 PCR screenings for toxigenic C. difficile carriage, 101 (16.1%) yielded positive findings. To establish clinical prediction rules in the derivation cohort, the formula was derived using significant predictors for toxigenic C. difficile carriage at admission, such as septic shock, connective tissue diseases, anemia, recent use of antibiotics, and recent use of proton-pump inhibitors. In the validation cohort, the sensitivity, specificity, and positive and negative predictive values of the prediction rule, based on a cut-off value of ≥ 0.45, were 78.3%, 70.8%, 29.5%, and 95.4%, respectively.ConclusionThis clinical prediction rule for identifying toxigenic C. difficile carriage at admission may facilitate the selective screening of high-risk groups. To implement it in a clinical setting, more patients from other medical institutions need to be prospectively examined.

A Multidisciplinary Approach to Outpatient Parenteral Antimicrobial Therapy Care

From the Division of Infectious Disease, Orlando Health Infectious Disease, Orlando, FL. Correspondence to: Aixa Curbelo-Irizarry, MD, FIDSA, Division of Infectious Disease, Orlando Health Infectious Disease, 1012 Lucerne Terrace, Orlando, FL 32806. E-mail: [email protected]. The author has no funding or conflicts of interest to disclose.

Are we ready to RESPOND that the question of abacavir's role in cardiovascular disease events is settled?

aDivision of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA bDepartment of Microbial Diseases, Centre for Experimental Pathogen Host Research, University College Dublin, School of Medicine, Belfield Dublin, Ireland. Correspondence to Carl J. Fichtenbaum, MD, Division of Infectious Diseases, University of Cincinnati College of Medicine, 231 Albert Sabin Way, P.O. Box 670560, Cincinnati, OH 45267-0560, USA. E-mail: [email protected] Received 17 November, 2022 Accepted 23 November, 2022

Patient characteristics and testing over COVID-19 waves 1 and 2 from the first German COVID-19 testing unit in Munich, Germany

BackgroundIn Munich, the first German case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected on 27 January 2020 at the Division of Infectious Diseases and Tropical Medicine of the University Hospital LMU Munich (DIDTM), and consecutively the Covid Testing Unit was established. Germany advocated several public health measures to control the outbreak. This study investigates the effects of measures on health service utilization in the public, which in turn can alter case numbers and test positivity rates.MethodOur retrospective observational study was conducted to determine the effects of public health measures on the utilization of a testing facility and positivity rates from the first operational COVID-19 testing facility in Munich for waves 1 and 2 over a period of 14 months. This was accomplished by comparing trends in client characteristics including age, gender, symptoms, and socio-demographic aspects over time to non-pharmaceutical measures in Germany. To depict trend changes in testing numbers over time, we developed a negative binomial model with multiple breakpoints.ResultsIn total 9861 tests were conducted on 6989 clients. The clients were mostly young (median age: 34), female (60.58%), and asymptomatic (67.89%). Among those who tested positive for SARS-CoV-2, 67.72% were symptomatic while the percentage was 29.06% among those who tested negative. There are other risk factors, but a SARS-CoV-2-positive colleague at work is the most prominent factor. Trend changes in the clients’ testing numbers could be attributed to the implementation of various public health measures, testing strategies, and attitudes of individuals toward the pandemic. However, test positivity rates did not change substantially during the second wave of the pandemic.ConclusionWe could show that implementation or changes in public health measures have a strong effect on the utilization of testing facilities by the general public, which independently of the true epidemiological background situation can result in changing test numbers.

Antimicrobial Resistance in Urinary Tract Infections: Is There an Issue and Does It Matter?

Antimicrobial resistance (AMR) has increased substantially among community-acquired uropathogens that cause urinary tract infections (UTI), limiting the availability of effective oral antibiotic treatments. This review includes coverage of an expert-led Learning Lounge, symposium session, and several poster presentations, that took place between 20th–22nd October 2022 as part of IDWeek2022 in Washington, D.C., USA. An immersive Learning Lounge, sponsored by GSK, opened with Keith Kaye, Department of Medicine, Rutgers–Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA, who illuminated the concerns of AMR in community-acquired UTIs, delivering contemporary surveillance data, and outlined how in vitro data may translate into practical advice. This led fittingly to Erin McCreary, Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania, USA, who enquired whether enough is being done in clinical practice regarding community-acquired infections, highlighting the importance of antimicrobial stewardship (AMS), and galvanising the audience to adapt healthcare settings to the changing landscape. The scientific programme also included three data-rich posters that showcased Kaye’s surveillance data on Escherichia coli and Klebsiella pneumoniae co-resistance, along with the geographical distribution of K. pneumoniae. An insightful poster by Claire Trennery, Value Evidence Outcomes, GSK, Brentford, UK, considered the patient perspective of UTI symptoms in defining antibiotic treatment success, and two posters presented by Rodrigo Mendes, JMI Laboratories, North Liberty, Iowa, USA, examined in vitro global surveillance data of emerging antimicrobial treatments.

Daptomycin-associated pulmonary toxicity sans eosinophilia in a hematopoietic cell transplant recipient with profound leukopenia.

Transplant Infectious DiseaseEarly View e14029 CLINICAL CORRESPONDENCE Daptomycin-associated pulmonary toxicity sans eosinophilia in a hematopoietic cell transplant recipient with profound leukopenia James Zou, James Zou Division of Infectious Diseases, Oregon Health and Science University School of Medicine, Portland, Oregon, USASearch for more papers by this authorJose Eduardo Rivera Sarti, Corresponding Author Jose Eduardo Rivera Sarti [email protected] [email protected] orcid.org/0000-0001-9106-017X Division of Infectious Diseases, Oregon Health and Science University School of Medicine, Portland, Oregon, USA Correspondence Jose Eduardo Rivera Sarti and Lynne Strasfeld, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code L-457, Portland, OR 97239, USA. Email: [email protected]; [email protected]; [email protected]Search for more papers by this authorLynne Strasfeld, Corresponding Author Lynne Strasfeld [email protected] orcid.org/0000-0003-2309-8146 Division of Infectious Diseases, Oregon Health and Science University School of Medicine, Portland, Oregon, USA Correspondence Jose Eduardo Rivera Sarti and Lynne Strasfeld, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code L-457, Portland, OR 97239, USA. Email: [email protected]; [email protected]; [email protected]Search for more papers by this author James Zou, James Zou Division of Infectious Diseases, Oregon Health and Science University School of Medicine, Portland, Oregon, USASearch for more papers by this authorJose Eduardo Rivera Sarti, Corresponding Author Jose Eduardo Rivera Sarti [email protected] [email protected] orcid.org/0000-0001-9106-017X Division of Infectious Diseases, Oregon Health and Science University School of Medicine, Portland, Oregon, USA Correspondence Jose Eduardo Rivera Sarti and Lynne Strasfeld, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code L-457, Portland, OR 97239, USA. Email: [email protected]; [email protected]; [email protected]Search for more papers by this authorLynne Strasfeld, Corresponding Author Lynne Strasfeld [email protected] orcid.org/0000-0003-2309-8146 Division of Infectious Diseases, Oregon Health and Science University School of Medicine, Portland, Oregon, USA Correspondence Jose Eduardo Rivera Sarti and Lynne Strasfeld, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code L-457, Portland, OR 97239, USA. Email: [email protected]; [email protected]; [email protected]Search for more papers by this author First published: 14 February 2023 https://doi.org/10.1111/tid.14029 James Zou and Jose Eduardo Rivera Sarti are co-first authors. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issuee14029 RelatedInformation

Editorial introductions.

Editorial introductions.

Chronic viral coinfections differentially affect the likelihood of developing long COVID.

BACKGROUNDThe presence and reactivation of chronic viral infections, such as EBV, CMV, and HIV, have been proposed as potential contributors to long COVID (LC), but studies in well-characterized postacute cohorts of individuals with COVID-19 over a longer time course consistent with current case definitions of LC are limited.METHODSIn a cohort of 280 adults with prior SARS-CoV-2 infection, we assessed the presence and types of LC symptoms and prior medical history (including COVID-19 history and HIV status) and performed serological testing for EBV and CMV using a commercial laboratory. We used covariate-adjusted binary logistic regression models to identify independent associations between variables and LC symptoms.RESULTSWe observed that LC symptoms, such as fatigue and neurocognitive dysfunction, at a median of 4 months following initial diagnosis were independently associated with serological evidence suggesting recent EBV reactivation (early antigen-diffuse IgG positivity) or high nuclear antigen (EBNA) IgG levels but not with ongoing EBV viremia. Serological evidence suggesting recent EBV reactivation (early antigen-diffuse IgG positivity) was most strongly associated with fatigue (OR = 2.12). Underlying HIV infection was also independently associated with neurocognitive LC (OR = 2.5). Interestingly, participants who had serologic evidence of prior CMV infection were less likely to develop neurocognitive LC (OR = 0.52).CONCLUSIONOverall, these findings suggest differential effects of chronic viral coinfections on the likelihood of developing LC and association with distinct syndromic patterns. Further assessment during the acute phase of COVID-19 is warranted.TRIAL REGISTRATIONLong-term Impact of Infection with Novel Coronavirus; ClinicalTrials.gov NCT04362150.FUNDINGThis work was supported by NIH/National Institute of Allergy and Infectious Diseases grants (3R01AI141003-03S1, R01AI158013, and K24AI145806); the Zuckerberg San Francisco General Hospital Department of Medicine and Division of HIV, Infectious Diseases, and Global Medicine; and the UCSF-Bay Area Center for AIDS Research (P30-AI027763).

Integrating Infectious Diseases and Preventive Medicine Specialties Into 1 Division: Experience of an Academic Medical Center

Throughout the coronavirus disease 2019 (COVID-19) pandemic, clinicians and researchers with appointments in separate divisions of infectious diseases (ID) and preventive medicine (PM) subspecialties collaborated on multiple projects, programmatic activities, and large-scale interventions at a tertiary academic medical center in the US Midwest. This collaboration was one of the reasons that prompted the integration of these groups into 1 unified academic division. Although this integrated structure is uncommon in the United States, the rationale, circumstances, and culture leading to this realignment may be common to other academic health systems.