Infectious Diseases Medicine Research Articles

Universal hepatitis B vaccination in adults aged 19–59 years: Updated recommendations of the advisory committee on immunization practices—United States, 2022

Universal hepatitis B vaccination in adults aged 19–59 years: Updated recommendations of the advisory committee on immunization practices—United States, 2022

Severe bacterial infections in people who inject drugs: the role of injection-related tissue damage

BackgroundIn the context of the current U.S. injection drug use epidemic, targeted public health harm reduction strategies have traditionally focused on overdose prevention and reducing transmission of blood-borne viral infections. Severe bacterial infections (SBI) associated with intravenous drug use have been increasing in frequency in the U.S. over the last decade. This qualitative study aims to identify the risk factors associated with SBI in hospitalized individuals with recent injection drug use.MethodsQualitative analysis (n = 15) was performed using an in-depth, semi-structured interview of participants admitted to Bellevue Hospital, NYC, with SBI and recent history of injection drug use. Participants were identified through a referral from either the Infectious Diseases or Addition Medicine consultative services. Interviews were transcribed, descriptively coded, and analyzed for key themes.ResultsParticipants reported a basic understanding of prevention of blood-borne viral transmission but limited understanding of SBI risk. Participants described engagement in high risk injection behaviors prior to hospitalization with SBI. These practices included polysubstance use, repetitive tissue damage, nonsterile drug diluting water and multipurpose use of water container, lack of hand and skin hygiene, re-use of injection equipment, network sharing, and structural factors leading to an unstable drug injection environment. Qualitative analysis led to the proposal of an Ecosocial understanding of SBI risk, detailing the multi-level interplay between individuals and their social and physical environments in producing risk for negative health outcomes.ConclusionsStructural factors and injection drug use networks directly impact drug use, injection drug use practices, and harm reduction knowledge, ultimately resulting in tissue damage and inoculation of bacteria into the host and subsequent development of SBI. Effective healthcare and community prevention efforts targeted toward reducing risk of bacterial infections could prevent long-term hospitalizations, decrease health care expenditures, and reduce morbidity and mortality.

Generalized infections of putative oral origin in Helsinki University Hospital in 2012 to 2017.

Bacteria entering the bloodstream through oral mucosa cause bacteremia, which can lead to septic or distant infections. The underlying factors and need for dental treatment in patients referred for oral examination because of septic infection were investigated. It was expected that general diseases and poor socioeconomic status of patients would increase the risk of bacteremia. This descriptive retrospective study included patients (N = 128) referred from medical clinics of the Helsinki University Hospital (HUH), during 2012 to 2017, to the Department of Oral and Maxillofacial Diseases due to bacteremia suspected to be of oral origin. Data were extracted from medical and dental records according to the World Health Organization International Classification of Diseases (ICD-10) for systemic or remote infections. Different groups were formed using modified Skapinakis classification for socioeconomic status (SES), from I (high) to V (low). Underlying medical conditions were retrieved according to McCabe classification: healthy, nonfatal, ultimately fatal, and rapidly fatal diseases. The data were analyzed using the statistical software package SPSS (IBM). Patients were referred most often from the Departments of Infectious Diseases and Internal Medicine. Because of infection, 12 patients needed aortic or mitral valve operations. Many of the patients were intravenous drug users. However, the majority of patients presented McCabe class I, indicating no systemic disease. The main SES was intermediate III. Tooth extraction was the principal mode of treatment. No demographic background variables were identified to explain increase of the risk for bacteremia except that most patients were men with untreated dental problems. Contrary to the authors' expectation, poor SES and underlying diseases did not seem to link to the outcome. However, untreated dental infections present an evident risk for life-threatening septic complications also in generally healthy individuals.

Quality of Conduct and Reporting of Propensity Score Methods in Studies Investigating the Effectiveness of Antimicrobial Therapy.

BackgroundPropensity score methods are becoming increasingly popular in infectious disease medicine to correct for confounding in observational studies. However, applying and reporting propensity score techniques correctly requires substantial knowledge of these methods. The quality of conduct and reporting of propensity score methods in studies investigating the effectiveness of antimicrobial therapy is yet undetermined.MethodsA systematic review was performed to provide an overview of studies (2005–2020) on the effectiveness of antimicrobial therapy that used propensity score methods. A quality assessment tool and a standardized quality score were developed to evaluate a subset of studies in which antibacterial therapy was investigated in detail. The scale of this standardized score ranges between 0 (lowest quality) and 100 (excellent).ResultsA total of 437 studies were included. The absolute number of studies that investigated the effectiveness of antimicrobial therapy and that used propensity score methods increased 15-fold between the periods 2005–2009 and 2015–2019. Propensity score matching was the most frequently applied technique (65%), followed by propensity score–adjusted multivariable regression (25%). A subset of 108 studies was evaluated in detail. The median standardized quality score per year ranged between 53 and 61 (overall range: 33–88) and remained constant over the years.ConclusionsThe quality of conduct and reporting of propensity score methods in research on the effectiveness of antimicrobial therapy needs substantial improvement. The quality assessment instrument that was developed in this study may serve to help investigators improve the conduct and reporting of propensity score methods.

Creation of a Multidisciplinary Drug Use Endocarditis Treatment (DUET) Team: Initial Patient Characteristics, Outcomes, and Future Directions.

BackgroundConsensus guidelines recommend multidisciplinary models to manage infective endocarditis, yet often do not address the unique challenges of treating people with drug use–associated infective endocarditis (DUA-IE). Our center is among the first to convene a Drug Use Endocarditis Treatment (DUET) team composed of specialists from Infectious Disease, Cardiothoracic Surgery, Cardiology, and Addiction Medicine. MethodsThe objective of this study was to describe the demographics, infectious characteristics, and clinical outcomes of the first cohort of patients cared for by the DUET team. This was a retrospective chart review of patients referred to the DUET team between August 2018 and May 2020 with DUA-IE.ResultsFifty-seven patients were presented to the DUET team between August 2018 and May 2020. The cohort was young, with a median age of 35, and injected primarily opioids (82.5% heroin/fentanyl), cocaine (52.6%), and methamphetamine (15.8%). Overall, 14 individuals (24.6%) received cardiac surgery, and the remainder (75.4%) were managed with antimicrobial therapy alone. Nearly 65% of individuals were discharged on medication for opioid use disorder, though less than half (36.8%) were discharged with naloxone and only 1 patient was initiated on HIV pre-exposure prophylaxis. Overall, the cohort had a high rate of readmission (42.1%) within 90 days of discharge.ConclusionsMultidisciplinary care models such as the DUET team can help integrate nuanced decision-making from numerous subspecialties. They can also increase the uptake of addiction medicine and harm reduction tools, but further efforts are needed to integrate harm reduction strategies and improve follow-up in future iterations of the DUET team model.

Clinical Evidence on the Use of Chinese Herbal Medicine for Acute Infectious Diseases: An Overview of Systematic Reviews.

Background: Acute infectious diseases constitute the most prevalent public health emergency (PHE) in China. Chinese herbal medicine (CHM) has long been used in the treatment of acute infections, but the overall evidence of its benefit and harm has not been comprehensively and systematically evaluated. Methods: We searched CBM, CNKI, Wanfang, PubMed, Cochrane Library, embase and preprint platforms to retrieve systematic reviews (SRs) on CHM for acute infectious. Participants with COVID-19, SARS, H1N1, tuberculosis, bacillary dysentery, mumps, herpangina, hand-foot-and-mouth disease (HFMD), and other acute infectious diseases were included. Interventional group consisting of patients treated with CHM combined with Western medicine or CHM alone. The AMSTAR 2 tool was used to assess the methodological quality of the retrieved studies. Information on interventions, control measures and outcomes of the included studies was extracted, and meta-analyses were qualitatively synthesized. Results: A total of 51 SRs and meta-analyses were eligible for this overview, including 19 for COVID-19, 11 for hand-foot-and-mouth disease, 8 for severe acute respiratory syndrome (SARS), 4 for tuberculosis, 3 for mumps, 2 for bacillary dysentery, 2 for H1N1 influenza and 2 for herpangina. Six systematic reviews were of high quality, all of which were on the use of CHM for COVID-19; 24 were of moderate quality; 10 were of low quality; and 11 were of very low quality. CHM appeared to have potential benefits in improving clinical symptoms and signs for most infections with an acceptable safety profile, and the clinical evidence of the benefits of CHM for acute respiratory infections such as COVID-19, SARS and H1N1 seems more sufficient than that for other acute infections. Conclusion: Overall, CHM, both decoction and Chinese patent medicine, used alone or in combination with conventional medicine may offer potential benefits to relieving symptoms of people with acute respiratory infections. Full reporting of disease typing, staging, and severity, and intervention details is further required for a better evidence translation to the responses for PHE. Future CHM research should focus mainly on the specific aspects of respiratory infections such as its single use for mild infections, and the adjunct administration for sever infections, and individual CHM prescriptions for well-selected outcomes should be prioritized.

Editorial introductions.

Editorial introductions.

Should Tetanus Vaccine Booster be Given Earlier in Individuals Living with HIV?

The incidence rate of tetanus has dramatically decreased following the discovery of the tetanus vaccine. A decennial booster dose is necessary to maintain the protective antibody levels after the primary vaccination schedule. The recommendations for the tetanus booster doses in adult "people living with acquired immune deficiency virus (HIV)" (PLWH) is similar to those for the general population. However, the duration of protective antibodies in PLWH is unknown. The aim of this study was to determine the factors affecting the response of HIV-infected individuals to tetanus vaccine and to evaluate the role of tetanus antitoxin level in determining the timing of the booster dose. PLWH attending the Adult Vaccination Unit of Ege University Faculty of Medicine Infectious Diseases and Clinical Microbiology Department were tested for tetanus antibodies from 30 October to 30 November 2020. Demographic information and the history of primary vaccination and booster doses were derived from medical files. Tetanus antibodies were detected with "enzyme immunoassay (EIA)" method with Clostridium tetani toxin 5S IgG-"enzyme linked immunosorbent assay (ELISA)" kit (Nova Lisa, Novatec Immundiagnostica, Germany). Antibody levels <0.01 IU/ml were considered negative, 0.01-0.5 IU/ml weak positive, 0.51-1.0 IU/ml positive and > 1.1 IU/ml strong positive. A level ≥ 0.50 IU/ml was considered as protective. The study included 146 PLWH [men (n= 126) and women (n= 40)]. The mean age was 39.5 ± 11.20 years (range: 18-65). Protective antibody level was detected in 114 (78.1%) participants. Receiver operating characteristics (ROC) analysis revealed that the ideal lower limit of CD4+ T cell count during booster vaccination for a person to develop protective antibody level was calculated as ≥ 218 cell/mm3. In the multivariate analysis, it was found that age <50 years (OR= 16.4, 95% CI= 4.9-55.2), the absence of AIDS at the time of diagnosis (OR= 6.7, 95% Cl= 1.05-17.4) and CD4+ T cell count ≥ 218 cells/mm3 at the time of vaccination (OR= 4.2, 95% CI= 1.05-17.4) were associated with protective levels of antibody. Protective levels of tetanus antibodies in PLWH are lower than the general population. It should be considered that the booster dose may be required earlier, especially in PLWH who are > 50 years old, with CD4+ T lymphocyte count <200 cells/mm3 during previous booster vaccination and who had AIDS at the time of the diagnosis.

Role of TGF-β1 and PDGF-B in Crimean-Congo hemorrhagic fever in Eastern Anatolia Region in Turkey.

In this study, we aimed to investigate the relationship between serum TGF-β1 and PDGF-B levels with the pathogenesis, clinical course and prognosis of adult Crimean-Congo hemorrhagic fever (CCHF) patients. 50 adult patients and 30 healthy individuals as a control group were included in the study, who were followed up and treated with the diagnosis of CCHF at the Atatürk University Faculty of Medicine Infectious Diseases and Clinical Microbiology Clinic, between March 2017 and September 2019 in Eastern Anatolia Region in Turkey. Blood samples were taken from patients on the first day of their hospitalization and on the sixth day of their complaints. TGF-β1 and serum PDGF-B levels were studied by ELISA method using commercial kits, from serum samples taken from CCHF patient group and individuals in healthy control group and stored at -80°C. While the serum TGF- β1 levels of patients with CCHF were found to be significantly higher on the sixth day of their complaints compared to the first day of hospitalization (42.33 ± 15.42, 28.40 ± 7.06, p = 0.001, respectively), the serum PGDF-B levels were found to be significantly lower on the sixth day of their complaints compared to those measured on the day of hospitalization (62.14 ± 19.75, 93.96 ± 20.02, respectively, p = 0.001). Serum TGF-β1 levels are higher and PDGF-B levels are lower in CCHF patients with severe disease, indicating that serum TGF-β1 and PDGF-B play an important role in the pathogenesis of CCHF.

COVID-19 outbreaks in hospital workers during the first COVID-19 wave.

BackgroundHealth care workers (HCWs) are on the frontline, playing a crucial role in the prevention of infection and treatment of patients.AimsThis study was aimed to evaluate the prevalence of hospital-acquired coronavirus disease 2019 (COVID-19) infection at work and related factors at the University Hospital of Trieste workers exposed to COVID-19 patients.MethodsFrom March 1 to May 31, of 4216 employees, 963 were in contact with COVID-19 patients or colleagues and were followed up. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in nasopharyngeal swabs was determined every 3 days, by RT-PCR.ResultsDuring the follow-up period, 193 workers were positive for COVID-19 (5%), and 165 of these (86%) were symptomatic. We identified five major cluster outbreaks of COVID-19 infection in Trieste Hospitals, four of which occurred before the implementation of universal masking for HCWs and patients (1–14 March 2020). COVID-19 infection was significantly higher in high-risk ward workers (Infectious Diseases, and Geriatric and Emergency Medicine, odds ratio [OR] 13.4; 95% confidence interval [CI] 5.8–31), in subjects with symptoms (OR 5.4; 95% CI 2.9–10) and in those with contacts with COVID-19 patients and colleagues (OR 2.23; 95% CI 1.01–4.9).ConclusionsHospital workers were commonly infected due to contact with COVID-19 patients and colleagues, mainly in the first 15 days of the pandemic, before the implementation of universal mask wearing of HCWs and patients. Repetitive testing and follow-up permitted the identification of COVID-19 cases before symptom onset, obtaining better infection prevention and control.

87. Infectious Disease Diversity, Equity, and Antiracism (ID2EA): A Dedicated Curriculum for Infectious Disease Professionals

BackgroundSystemic bias in the health care system has adverse effects on health outcomes. Educational programs examining the relationship between structural racism and health inequities are needed to translate knowledge into equitable care. The Yale School of Medicine Infectious Disease (ID) Section designed and piloted an innovative Infectious Disease Diversity, Equity, and Anti-Racism (ID2EA) curriculum to better understand and confront these issues.MethodsThe ID Section collaborated with pedagogical experts to create a curriculum. A baseline survey of ID faculty and trainees was used to gauge relevant knowledge, attitudes, skills, and topics of interest to participants. The curriculum was designed as a “roadmap” of interactive sessions (“roadmap stops”) focused on topics identified by respondents. Evaluations were performed after events to guide curriculum development and monitor its acceptance and effectiveness.ResultsAll respondents (n=28) to the baseline survey agreed that discussion of race and ethnicity should be integrated into medical training. Most respondents (96%) had experience or knowledge of racial microaggressions in the workplace. Fewer (75%) felt comfortable talking to patients about race and only 68% felt confident teaching learners how to decrease bias in care. The survey identified topics of highest priority to participants, including building trust with patients (75%), providing racially sensitive care (68%) and establishing dialogue with community members (57%). Roadmap stops were constructed based on these priorities, with sessions on race-based medical experimentation and inequities, racial segregation and its impact on health, medical mistrust, and a skill building session on improving patient-centered communication. On follow-up surveys (n=18-28), most participants (93%) saw the sessions as a valuable way to spend time and the majority (91%) reported an impact on their understanding of racism in healthcare; specific changes in thinking were qualitatively coded. ConclusionOur findings demonstrate the positive impact of a curriculum to help understand racism and inequities in medicine. Building and implementing a diversity, inclusion, and anti-racism curriculum in ID sections is feasible, beneficial, and valued.Disclosures Jaimie Meyer, MD, Gilead Sciences (Scientific Research Study Investigator) Sheela Shenoi, MD, MPH, Merck (Other Financial or Material Support, SS’s spouse worked for Merck pharmaceuticals 1997-2007 and retains company stock in his retirement account. There is no conflict of interest, but it is included in the interest of full disclosure.) Marjorie Golden, MD, Iterum Pharmaceuticals (Consultant)

Multidisciplinary team approach to confront the challenge of drug use–associated infective endocarditis

ObjectivesDrug use–associated infective endocarditis is a rapidly growing clinical problem. Although operative outcomes are generally satisfactory, reinfection secondary to recurrent substance use is distressingly common, negatively affects long-term survival, generates practical and ethical challenges, and creates potential conflict among care team members. We established a Drug Use Endocarditis Treatment team including surgeons, infectious disease, and addiction medicine experts specifically focused on the unique complexities of drug use–associated infective endocarditis. MethodsWe reviewed the impact of Drug Use Endocarditis Treatment team involvement on quantitative measures of quality of care, including length of stay, time to addiction medicine consultation, time to surgery, and discharge on appropriate medications for opioid use disorder, as well as operative mortality. Standard statistical tests were used, including the Fisher exact test, t test, and Wilcoxon rank-sum test. Qualitative assessment was made of the impact on clinicians, including communication and mutual understanding. ResultsComparing the pre–Drug Use Endocarditis Treatment cohort with the post–Drug Use Endocarditis Treatment cohort, patients in the post–Drug Use Endocarditis Treatment cohort who underwent surgery had a significantly lower time from admission to addiction medicine consultation (3.8 vs 1.0 days P < .001) and clinically relevant increase in discharge on medications for opioid use disorder (48% vs 67% P = .35). Additionally, involved members of the team thought communication was improved. ConclusionsThe Drug Use Endocarditis Treatment team improved engagement with addiction medicine consultation and appropriate discharge care. Given the impact of relapse of injection drug use on long-term outcomes, interventions such as this offer potentially powerful tools for the treatment of this complex patient population.

133 Value-based care for healthy children with first episode of febrile neutropenia

Abstract Primary Subject area Emergency Medicine - Paediatric Background While the management of febrile neutropenia in patients with cancer has clear, evidence-based guidelines, the management of previously healthy, immunocompetent children with a febrile illness and first episode of neutropenia is less understood. These patients are often similarly treated with empiric antibiotics and hospitalization despite studies demonstrating that this population, if they are well-appearing with a short history of neutropenia, is at low risk of serious bacterial infections. Therefore, less aggressive management should be considered in patients meeting low risk criteria. Objectives The aim of our quality improvement (QI) study was to decrease the number of unnecessary hospitalizations and empiric antibiotics prescribed by 50% over a 12-month period for otherwise healthy, well appearing patients presenting to the emergency department (ED) with a first episode of febrile neutropenia. Design/Methods A team of stakeholders from Hematology, Infectious Disease, Pediatrics and Emergency Medicine was assembled. A review of the literature, peer institutions and local practices of managing febrile neutropenia in healthy children was performed. Using the Model for Improvement, a guideline for the management of healthy children with first episode of febrile neutropenia was developed and refined using PDSA cycles. In January 2020, the guideline was launched for clinical use in the ED. Education, targeted audit and feedback, pathway modifications, and reminders were used to address knowledge gaps and staff turnover. A family of measures was analyzed using run charts and statistical process control (SPC) methods. Results Eighteen months of baseline data identified nineteen low risk patients with 84% either hospitalized and/or received antibiotics. It was also uncovered that many patients were misdiagnosed with neutropenia by excluding bands from the absolute neutrophil count (ANC). After the first twelve months of the intervention, sixteen patients met low risk criteria. Hospitalization and/or antibiotics use for this population decreased to 25% and all blood cultures were negative. Recognition of true severe febrile neutropenia also improved. Forty-one patients had a neutrophil count &amp;lt; 0.5, but an ANC &amp;gt; 0.5. Hospitalization and/or antibiotics use for this population decreased from 52% to 10%. Conclusion Through a multi-faceted, multidisciplinary QI study, we improved resource stewardship and value-based care by reducing unnecessary hospitalizations and antibiotics in low risk patients with a first episode of febrile neutropenia. Next steps include iterations to the guideline to increase impact along with sustainability planning. This work can easily be adopted by other pediatric and community sites caring for children.

Leprosy chemoprophylaxis of household contacts: A survey of Canadian infectious disease and tropical medicine specialists.

Leprosy is uncommon in Canada. However, immigration from leprosy-endemic areas has introduced the infection to a Canadian context, in which most doctors have little knowledge of the disease. Although post-exposure chemoprophylaxis (PEP) is reported to decrease leprosy transmission, no Canadian guidelines advise clinical decision making about leprosy PEP. Here, we characterize the practice patterns of Canadian infectious disease specialists with respect to leprosy PEP and screening of household contacts by yearly physical examinations. Canadian infectious disease specialists with known experience treating leprosy were identified using university faculty lists. An online anonymous survey was distributed. Certain questions allowed more than one response. The survey response rate was 46.5% (20/43). Thirty-five percent responded that PEP is needed for household contacts, 40.0% responded that PEP is not needed for household contacts, and 25.0% did not know whether PEP is needed (multinomial test p = 0.79). Twenty-five percent responded that PEP should be given to all household contacts, 62.5% responded that PEP should be given to contacts of multibacillary cases, and 25.0% responded that PEP should be given to contacts who are genetically related to the index case. For specialists who prescribe PEP, 57.1% use rifampicin, ofloxacin (levofloxacin), and minocycline; 14.3% prescribe single-dose rifampicin; and 28.6% prescribe multiple doses of rifampicin (multinomial test p = 0.11). In addition, 68.4% recommend yearly screening of household contacts, whereas 31.6% do not (multinomial test p = 0.17). Consensus among Canadian infectious diseases specialists is lacking regarding leprosy PEP and screening of household contacts.

Characterization of antioxidant and antibacterial compounds from aerial parts of Haplophyllum tuberculatum

The aerial parts of Haplophyllum tuberculatum (H. tuberculatum) have traditionally been used by local communities to treat fever, gastrointestinal disorders, worms, malaria and fractures, however, the responsible ingredients of the selected medicinal plant have not been identified. In the present study, antibacterial and antioxidant ingredients were isolated and characterized from the plant parts of locally grown H. tuberculatum, and their biological activity was evaluated. The powder aerial parts were extracted with methanol and the extract was successively fractionated with different polarities of solvents. All polarities of extracts (hexane, chloroform, ethyl acetate, butanol, methanol and water) were used to determine their antibacterial and antioxidant activity by established in-vitro method. The disk diffusion and free radical scavenging 2,2-diphenyl-1-picrylhydrazyl (DPPH) methods were used to evaluate antibacterial and antioxidant activities of the prepared extracts and pure isolated compounds at different concentrations against three strains of Gram-positive and three Gram-negative bacteria. The antibacterial activity results showed that all prepared fractions and isolated pure compounds of the plant species gave significant activity against all Gram (+ and –) bacterial strains with the range of inhibition 0–20 mm. The antioxidant activity of the prepared extracts at all concentrations also showed substantial activity. Based on the highest activity, ethyl acetate and chloroform extracts were selected for the separation and isolation of antioxidant and antibacterial compounds by thin layer chromatography (TLC), column chromatography (CC), and preparative thin layer chromatography (PTLIC). The structure of the isolated antioxidant and antibacterial compounds from the ethyl acetate and chloroform extracts were determined on the basis of nuclear magnetic resonance (NMR) and mass spectra. The isolated pure compounds and active extracts could be used as a medicine for various infectious related diseases.

Harnessing the Potential of Multiomics Studies for Precision Medicine in Infectious Disease.

The field of infectious diseases currently takes a reactive approach and treats infections as they present in patients. Although certain populations are known to be at greater risk of developing infection (eg, immunocompromised), we lack a systems approach to define the true risk of future infection for a patient. Guided by impressive gains in “omics” technologies, future strategies to infectious diseases should take a precision approach to infection through identification of patients at intermediate and high-risk of infection and deploy targeted preventative measures (ie, prophylaxis). The advances of high-throughput immune profiling by multiomics approaches (ie, transcriptomics, epigenomics, metabolomics, proteomics) hold the promise to identify patients at increased risk of infection and enable risk-stratifying approaches to be applied in the clinic. Integration of patient-specific data using machine learning improves the effectiveness of prediction, providing the necessary technologies needed to propel the field of infectious diseases medicine into the era of personalized medicine.

Type 1 Diabetes Mellitus

As has been the case in many areas of child and adolescent health and in medicine in general, the recent Covid19 pandemic has affected children and adolescents with type 1 diabetes (T1D) and their families very much. In addition, health system resources have been allocated to adult care infectious disease and pulmonary medicine departments. Pediatric care and pediatric health care structures have suffered (1-3). Still, a number of important publications have been made available within the last year which shed new light on many aspects of T1D in early life and will allow to improve the care for children and adolescents with T1D.

Dermatology in a multidisciplinary approach with infectious disease and obstetric medicine against COVID-19.

The care for patients infected with COVID-19 requires a team approach, and dermatologists may collaborate with other specialties, especially infectious disease (ID) medicine and obstetrics and gynecology (ObGyn), at every stage of the infection process. A broad spectrum of cutaneous manifestations may occur early in COVID-19 infection, making appropriate dermatologic identification critical for an early diagnosis. There is prognostic value in appropriately identifying different types of COVID-19–associated skin manifestations, which have been linked to disease severity. Such observations emanated from dermatology research, especially large series and international registries of cutaneous manifestations relating to COVID-19, and impact COVID-19 care provided by most health care providers. Also, research based on international registries of skin reactions from the COVID-19 vaccines has an impact across disciplines. An increased risk for severe illness from COVID-19 is encountered during pregnancy, and dermatologists’ role is to urge ObGyn and other clinicians to monitor and educate pregnant patients about the potential for eruptions as a manifestation of COVID-19. ID and ObGyn experts indicate that teledermatology enhanced the interaction among health care providers and improved COVID-19 care. More than 40% of all dermatology consultations at a tertiary care hospital were done via teledermatology. Future collaborative research involving dermatology and specialties, such as ID and ObGyn, could help delineate guidelines for dermatology consultations in patients infected with COVID-19 and determine cases appropriate for teledermatology.

Multidisciplinary Management of Complicated Pancreatitis: What Every Interventional Radiologist Should Know.

Management of acute pancreatitis is challenging in the presence of local complications that include pancreatic and peripancreatic collections and vascular complications. This review, targeted for interventional radiologists, describes minimally invasive endoscopic, image-guided percutaneous, and surgical procedures for management of complicated pancreatitis and provides insight into the procedures' algorithmic application. Local complications are optimally managed in a multidisciplinary team setting that includes advanced endoscopists; pancreatic surgeons; diagnostic and interventional radiologists; and specialists in infectious disease, nutrition, and critical care medicine. Large symptomatic or complicated sterile collections and secondary infected collections warrant drainage or débridement. The drainage is usually delayed for 4-6 weeks unless clinical deterioration warrants early intervention. If collections are accessible by endoscopy, endoscopic procedures are preferred to avoid pancreaticocutaneous fistulas. Image-guided percutaneous drainage is indicated for symptomatic collections that are not accessible for endoscopic drainage or that present in the acute setting before developing a mature wall. Peripancreatic arterial pseudoaneurysms should be embolized before necrosectomy procedures to prevent potentially life-threatening hemorrhage. Surgical procedures are reserved for symptomatic collections that persist despite endoscopic or interventional drainage attempts. Understanding these procedures facilitates their integration by interventional radiologists into the complex longitudinal care of patients with complicated pancreatitis.

Disease Severity in Cancer Patients Infected With SARS-COV-2: An Ambiguous Issue.

To the Editor: Patients with cancer are considered more susceptible to SARS-CoV-2 infection. One of the serious complications of COVID-19 is hyperactivation of the immune system, which induces an uncontrolled production of cytokines that poses a high mortality. Although a weakened immune system may be harmful in the initial phase of COVID-19, the phase that the immune response is necessary to inhibit viral replication, in immunocompromised patients, an attenuated inflammatory response may not be associated with development of severe COVID-19 and also cytokine storm, due to suppression of some pathway of cellular or humeral responses1; hence, immunosuppression might have a beneficial effect on the cytokine release storm phase of COVID-19 in these groups of patients. On the other hand, several immunosuppressive drugs and chemotherapeutic agents used in these patients that have direct inhibitory effects on SARS-CoV-2 replication in vitro or induce potentially increased vulnerability to this virus are known.2 With the onset of the coronavirus pandemic, studies on the relationship between viral load and disease severity have been performed. It is unknown whether viral load really affects the disease severity or not. Some studies showed that viral load has important prognostic implications and could therefore help identify patients who are at highest risk for adverse outcomes. In addition, it was shown that, compared with patients with mild disease, those with severe disease showed higher viral load and a later shedding peak.3,4 On the other hand, it has been shown that viral load based on cycle threshold values seem to be different in solid tumors versus hematologic malignancies in patients undergoing chemotherapy. One study showed that patients with hematologic malignancies had higher viral loads than did patients with solid tumors or patients without cancer. This finding may be from the underlying immunodeficiencies and therapies administered that confer a decreased ability to inhibit the proliferation of a virus without a statistically significant increase in mortality among patients with hematologic malignancies versus patients with solid tumors or patients without cancer.5 In another study, Ju et al6 reported 2 cancer patients, 1 with critical type and 1 asymptomatic carrier, who were undergoing or just completed chemotherapy treatment, respectively, with favorable outcomes after being infected with COVID-19. The authors reported a low viral load level in both patients despite receiving chemotherapy. Whether cancer itself is an independent risk factor for severe COVID-19 remains to be clarified. What seems to be important is not a single factor, but the host immune system, viral load, immunosuppressive drugs' effects on virus replication and phase of disease, and chemotherapy may play a role that determines the severity of the disease. More studies are needed to clarify this association. Masoud Mardani, MDAtousa Hakamifard, MD Infectious Diseases and Tropical Medicine Research Center Shahid Beheshti University of Medical Sciences Tehran, Iran [email protected]