Posttransfusion hepatitis in Toronto, Canada

Five hundred seventy-six consecutive patients from the surgical, obstetrical, and medical services who had received transfusions of volunteer blood were followed-up at regular intervals for 6 mo. Fifty-three (9.2%) developed acute posttransfusion non A, non B hepatitis. Forty-seven (89%) had an incubation period between 2 and 8 wk. The frequency was not related to the age or sex of the patient, the indications for transfusion, the type of surgery, anesthesia, the presence of perioperative hypotension, or the number of units of blood transfused. There were no cases of fulminant hepatitis. Nineteen of the 53 patients (36%) with acute posttransfusion hepatitis progressed to chronic hepatitis. Development of chronic hepatitis was not related to the age or sex of the patient, the incubation period of the preceding acute hepatitis, the presence of shock or malignancy, or the number of units of blood transfused. Patients with higher levels of alanine aminotransferase during the acute hepatitis were more prone to develop chronic hepatitis. The finding of 9.2% of transfusion-related hepatitis in recipients of hepatitis B surface antigen-screened blood from volunteer donors underscores the potential sequelae of blood transfusion, especially as a source of contribution to the pool of chronic liver disease.     

Hepatitis B viremia in HIV-coinfected individuals under antiretroviral therapy

BackgroundAntiretroviral therapy (ART) has decreased AIDS incidence and mortality, rendering comorbidities, such as hepatitis B more relevant for people living with human immunodeficiency virus (HIV). Since antiretroviral drugs may also inhibit hepatitis B virus (HBV) replication, analyzing the impact of ART on management of hepatitis B in this population is important.ObjectiveTo assess HBV viremia among HIV/HBV coinfected individuals on ART and its associated factors.MethodFor this cross-sectional study, HIV/HBV-coinfected individuals, aged over 18 years, who were on ART for over six months and receiving care at an outpatient clinic in São Paulo were recruited. Sociodemographic characteristics, information about viral exposure, clinical and laboratory data, including evaluation of liver fibrosis were obtained. Plasma HBV DNA was measured by polymerase chain reaction. Viral genome sequencing was conducted for genotyping and identification of drug resistance-conferring mutations if viral load exceeded 900 IU/mL.ResultsOut of 2,946 patients who attended the clinic in 2015, 83 were eligible and 56 evaluated. Plasma HBV DNA was detected in 16 (28.6%) (95% CI: 18.0–41.3%), all on lamivudine and tenofovir treatment. HBV DNA detection was associated with lower education (p = 0.015), higher international normalized ratios (p = 0.045), history of an AIDS-defining illness [OR: 3.43 (95% CI: 1.10–11.50)], and HBeAg detection [OR: 6.60 (95% CI: 1.84–23.6)]. In contrast, a last CD4+ count above 500 cells/mm³ in the year prior to inclusion [OR: 0.18 (95% CI: 0.04–0.71)] and detection of anti-HBe [OR: 0.21 (95% CI: 0.04–0.99)] were negatively associated. Patients with HBV DNA above 900 IU/mL were infected with subgenotypes A1 (n = 3) and D2 (n = 1), and exhibited viral mutations associated with total resistance to lamivudine and partial resistance to entecavir.ConclusionsDespite being on ART, a significant proportion of HIV/HBV-coinfected individuals present HBV viremia. Characterization of factors that are associated with this finding may help professionals provide better management to these patients.     

Prevalence and characteristics of post-partum thyroid dysfunction: results of a survey from Toronto, Canada.

In order to determine the prevalence of post-partum thyroid dysfunction in our region, 1,376 randomly selected mothers were enrolled immediately post-partum and followed prospectively over a 2 year period in a large single-center survey. Beginning at delivery, sequential clinical and laboratory assessments were conducted at 6-8 week intervals up to 1 year post-partum and a questionnaire was administered at 3 months post-partum. Among the 1,376 mothers who qualified for entry into this study, 495 (36%) completed at least 3 months follow-up and 300 (22%) completed at least 1 year of follow-up. Abnormalities in post-partum thyroid function (PTD) were detected in 82 of the 1,376 enrolled mothers for an overall minimum prevalence rate of 6.0%. Hyperthyroidism confirmed to be associated with a low 24h radioactive iodine thyroid uptake (RAIU), compatible with the post-partum painless thyroiditis syndrome (PPT) was documented in 44 (3.2% minimum prevalence of typical PPT) of which 39 (89%) had a typical biphasic (hyperthyroid to hypothyroid) PTD while 5 (11%) had only a hyperthyroid phase with a suppressed RAIU without a subsequent hypothyroid phase. Another 17 (1.2%) had transient hyperthyroidism likely due to PPT but were not confirmed by an RAIU test and did not evolve to a detectable hypothyroid phase; and, 17 mothers (1.2%) had hypothyroidism between 5-7 months post-partum without preceding hyperthyroidism, resulting in an overall minimum prevalence of 5.7% for all variants of PPT. Graves' hyperthyroidism occurred in 3 (0.2%) and toxic nodular goiter was present in 1 (0.07%).(ABSTRACT TRUNCATED AT 250 WORDS)     

High retention in HIV care at a tertiary care centre in Toronto,Canada*

Poor retention in HIV care is associated with poor clinical outcomes and mortality. Previous studies of predictors of poor retention have been conducted with a wide variety of populations, using different measures of retention, and occasionally have conflicting results. We studied demographic and psychosocial factors associated with inter-visit interval length in a setting of universal health care and modern cART. Patients attending ≥2 appointments with an HIV specialist at the Toronto General Hospital Immunodeficiency Clinic from 2004 to 2013 were studied. A sub-analysis included psychosocial measures from annual questionnaires for Ontario HIV Treatment Network Cohort Study (OCS) participants. Median inter-visit interval and constancy (percentage of 4-month intervals with ≥1 visit) were calculated by patient. Multivariable generalized estimating equation models identified factors associated with inter-visit interval length and intervals ≥12 months. 1591 patients were included. 615 patients completed an OCS questionnaire and were more likely to be older white MSM from Canada with a viral load (VL) <50 copies/ml. The median (IQR) of patients’ median inter-visit intervals was 3.15 (2.78, 3.84) months and median (IQR) constancy was 90% (71%, 100%). Two percent of inter-visit intervals were ≥12 months and 25% of patients had ≥1 interval ≥12 months. Longer inter-visit intervals were associated with younger age, white race, earlier calendar year, longer duration of HIV, VL < 50 copies/mL and higher CD4 counts. Patients who were younger, white, had injection drug use as a risk factor, had a longer duration of HIV, and had VL ≥50 copies/mL were more likely to have an inter-visit interval ≥12 months. In the OCS sub-analysis including psychosocial variables, lower levels of depression were associated with longer inter-visit intervals. Retention at this tertiary care centre was high. Efforts to maximize attendance should focus on younger patients and those with substance abuse issues.     

Endoscopy in Canada: Proceedings of the National Roundtable: Toronto,Ontario, February 7, 2014

This 2014 roundtable discussion, hosted by the Canadian Association of General Surgeons, brought together general surgeons and gastroenterologists with expertise in endoscopy from across Canada to discuss the state of endoscopy in Canada. The focus of the roundtable was the evaluation of the competence of general surgeons at endoscopy, reviewing quality assurance parameters for high-quality endoscopy, measuring and assessing surgical resident preparedness for endoscopy practice, evaluating credentialing programs for the endosuite and predicting the future of endoscopic services in Canada. The roundtable noted several important observations. There exist inadequacies in both resident training and the assessment of competency in endoscopy. From these observations, several collaborative recommendations were then stated. These included the need for a formal and standardized system of both accreditation and training endoscopists.     

Intussusception in a private tertiary-care hospital, Bangkok, Thailand: a case series

This was a retrospective case series study of patients with intussusception at a private tertiary-care hospital in Bangkok, Thailand. The computerized hospital records of all 94 children aged 0-14 years diagnosed with intussusception from 2000 to 2005 were reviewed. About half (51.1%) were males, 23.4% were less than 1 year old. Most (78.7%) were Thai nationals. The highest case frequency was in August (n=12, Poisson means = 7.8, 95% confidence interval 6.3-9.6). Of these, none had the classical triad of vomiting, colicky pain, and mucous bloody stools. Only 12.8% had fever; abdominal mass was detected in 4.3%, and 4.3% had increased bowel sounds, while 34.0% had no specific signs. The most frequent site of intussusception was the ileocolic (62.6%). Stool cultures for bacteria and stool for rotavirus antigen obtained in some cases revealed no significant findings. Of the cases, 10 (10.6%) had spontaneous reduction, 84 (89.4%) underwent barium enema intervention, 10 of the latter (11.9%) required further surgical intervention. There were no mortalities during the observation period. There were 10 recurrent events in this series. The 7-day recurrence-free probability was 84.9% (95% CI 49.2, 96.3%). This study provides baseline data regarding intussusception in Thailand which may be useful for future epidemiological and/or clinical studies.     

Quetiapine poisoning: a case series

STUDY OBJECTIVE: We describe the effects of quetiapine in overdose. METHODS: Quetiapine poisonings were identified from a prospective database of poisoning admissions to a regional toxicology service. Data extracted included details of ingestion, clinical features, investigations (including ECG), and other outcomes (length of stay and ICU admission rate). RESULTS: There were 45 cases of quetiapine overdose, of which 18 patients with quetiapine assay results were included. Median length of stay was 35 hours (interquartile range [IQR] 14 to 42 hours) for the 18 patients, and 9 were admitted to the ICU. The median ingested dose was 3.5 g (IQR 1.7 to 6.2 g), and reported ingested dose was highly correlated with estimated peak drug concentration (r(2)=0.84; P<.0001), confirming patient-provided history of ingestion. Seizures occurred in 2 patients, delirium occurred in 3 patients, and mechanical ventilation was required in 4 patients. No arrhythmias or deaths occurred. Six of the 18 patients ingested quetiapine alone, with a median length of stay of 35 hours, and 3 were admitted to the ICU. In 1 patient who ingested 24 g, hypotension and seizures occurred. For 10 patients for whom ECGs were available and who had ingested no cardiotoxic drugs, tachycardia occurred in 8 patients. For these 10 patients, the mean corrected QT (QTc) interval was increased at 487 ms, but the mean uncorrected QT interval was 349 ms. Reported dose and peak quetiapine concentrations were significantly associated with ICU admission and length of stay more than 24 hours. A reported dose less than 3 g and a Glasgow Coma Scale score not less than 15 predicted patients not requiring ICU admission or length of stay more than 24 hours. CONCLUSION: Quetiapine overdose causes central nervous system depression and sinus tachycardia. In large overdoses, patients may require intubation and ventilation for associated respiratory depression. Although a prolonged QTc occurs, its clinical significance is unclear because it is most likely caused by an overcorrection caused by the tachycardia. In our experience, a reported dose of less than 3 g for patients who are not drowsy (with a Glasgow Coma Scale score of 15) at least 4 hours after ingestion and who did not coingest another toxic agent defined a group not requiring ICU admission or inpatient admission greater than 24 hours.     

Ciprofloxacin-warfarin coagulopathy: a case series

Ciprofloxacin, when given to patients previously anticoagulated with warfarin, can occasionally cause an exaggerated hypoprothombinemic response and bleeding diatheses. Two such cases encountered at our institution are presented and data is combined with 64 cases reported to the Food and Drug Administration's (FDA) Spontaneous Reporting System (SRS) database, which included all cases reported from 1987 through 1997. Of 66 total cases the median age was 72 (range 36-94). The mean time to detection of the coagulopathy following the ciprofloxacin challenge was 5.5 days (n = 50). Hospitalization was reported in 15 cases, bleeding in 25 cases, and death in one case. The median prothrombin time (PT) and International Normalized Ratio (INR) was 38.0 (n = 13) and 10.0 (n = 23), respectively. The mean number of medications taken was 6.5 (n = 45). The mean time to correction was significantly shorter between the treated (2.5 days) and the untreated (4.0 days) groups (P < 0. 008). The ciprofloxacin-warfarin coagulopathy occurred most commonly in patients in their seventh decade and in those who require polypharmacy. Active treatment of the coagulopathy results in more rapid resolution than observation alone. Clinicians should be aware of the potential bleeding complications that can occur with the ciprofloxacin-warfarin drug-drug interaction.     

Raltegravir in pregnancy: a case series presentation

Adequate antiretroviral therapy is essential for HIV-positive pregnant women to prevent mother-to-child transmission. We report a small case series of five women receiving raltegravir as part of their antiretroviral regimen during pregnancy.     

Coccidioidomycosis in non-endemic areas: a case series

Coccidioidomycosis is a systemic infection caused by the soil fungus Coccidioides immitis, which is endemic to the south-western United States. Manifestations range from flu-like illness to pneumonia and septic shock. Diagnosis may be delayed or missed in non-endemic areas because of the low index of suspicion. We describe a series of 23 patients with coccidioidomycosis at one institution in a non-endemic area. Diagnosis was often delayed. In two patients, the route of exposure could not be determined, but 20 patients had a history of residence or travel to endemic areas, and the remaining patient had an occupational history of exposure to fomites from an endemic region. Five patients were immunosuppressed. Most patients responded well to medical therapy, surgery, or both. Although coccidioidomycosis is rare in non-endemic areas, physicians must keep it in mind when evaluating patients who have traveled to endemic areas or who are immunosuppressed.     

A Hospital Partnership with a Nursing Home Experiencing a COVID-19 Outbreak: Description of a Multiphase Emergency Response in Toronto,Canada

Nursing homes have become “ground zero” for the coronavirus disease 2019 (COVID-19) epidemic in North America, with homes experiencing widespread outbreaks, resulting in severe morbidity and mortality among their residents. This article describes a 371-bed acute-care hospital's emergency response to a 126-bed nursing home experiencing a COVID-19 outbreak in Toronto, Canada. Like other healthcare system responses to COVID-19 outbreaks in nursing homes, this hospital–nursing home partnership can be characterized in several phases: (1) engagement, relationship, and trust building; (2) environmental scan, team building, and immediate response; (3) early-phase response; and (4) stabilization and transition period. J Am Geriatr Soc 68:1376-1381, 2020.     

HIV and tuberculosis co-infection in south-western Sydney: experience from a case series

A case series of six patients with HIV and Mycobacterium tuberculosis co-infection is presented. All patients were overseas-born and in all but one there was profound immunodeficiency. We recommend HIV screening of all cases of M. tuberculosis and a high degree of suspicion of tuberculosis in immigrants with HIV infection from endemic areas. Management problems included delayed diagnosis, rapid progression, paradoxical reactions and requirement for surgical intervention in three patients. Therapeutic complications included possible drug malabsorption, adverse events and drug interactions. M. tuberculosis was fully drug sensitive in all cases.     

Biphenotypic acute leukaemia: a case series

Biphenotypic acute leukaemia (BAL) is a rare type of leukaemia. Whether patients with BAL should be treated with regimens designed for acute myeloid leukaemia (AML), acute lymphocytic leukaemia (ALL) or both remain unclear. We have reviewed the clinical data for 31 BAL patients. Most patients co-expressed B-lymphoid and myeloid markers. No specific chromosomal abnormality was identified. The majority of the patients were treated with regimens devised for treating ALL. Seven patients were treated with regimens designed for AML. Complete remission (CR) rates of 78% and 57% were noted respectively. The overall survival probability at 2 years was 60%.