Daniel A. Green

Clinical Utility of On-Demand Multiplex Respiratory Pathogen Testing among Adult Outpatients.

ABSTRACT Multiplex tests for respiratory tract infections include up to 20 targets for common pathogens, predominantly viruses. A specific therapeutic intervention is available for individuals testing positive for influenza viruses (oseltamivir), and it is potentially beneficial to identify non-influenza viruses to avoid unnecessary antibiotic use. We evaluated antimicrobial prescriptions following respiratory pathogen testing among outpatients at a large Veterans Administration (VA) medical center. Results of the FilmArray respiratory panel (BioFire, Salt Lake City, UT) from 15 December 2014 to 15 April 2015 were evaluated among 408 outpatients, and patient medical records were reviewed. Differences in antibiotic and oseltamivir prescription rates were analyzed. Among 408 patients tested in outpatient centers (emergency departments, urgent care clinics, and outpatient clinics), 295 (72.3%) were managed as outpatients. Among these 295 outpatients, 105 (35.6%) tested positive for influenza virus, 109 (36.9%) tested positive for a non-influenza virus pathogen, and 81 (27.5%) had no respiratory pathogen detected. Rates of oseltamivir and antibiotic prescriptions were significantly different among the three test groups (chi-squared values of 167.6 [P < 0.0001] and 10.48 [P = 0.005], respectively), but there was no significant difference in antibiotic prescription rates between the non-influenza virus pathogen group and those who tested negative (chi-square value, 0; P = 1.0). Among adult outpatients, testing positive for influenza virus was associated with receiving fewer antibiotic prescriptions, but no such effect was seen for those who tested positive for a non-influenza virus. These data suggest that testing for influenza viruses alone may be sufficient and more cost-effective than multiplex pathogen testing for outpatients.

Scleroderma and its oral manifestations: Report of three cases of progressive systemic sclerosis (diffuse scleroderma)

Abstract 1. 1. Three cases of scleroderma have been presented to show the systemic and oral manifestations of the disease. 2. 2. The dentist should recognize the importance of this rare disease and refer the patient to a qualified authority for definitive treatment. 3. 3. In all three of the cases reported here there was rigidity of the lips, with difficulty in retracting them. 4. 4. Crippling of the hands was present in the three patients, and shortness of breath was noted while the patients were resting. A gasping for air seemed to be typical in all three cases. 5. 5. The characteristic dental roentgenographic finding of widening of the periodontal membrane was observed in one of the three patients seen.

A pediatric case of New Delhi metallo-β-lactamase-1-producing Enterobacteriaceae in the United States.

We report the second pediatric case of New Delhi metallo-β-lactamase-1-producing Enterobacteriaceae in the United States. Laboratory methods included various phenotypic antimicrobial susceptibility testing assays, as well as polymerase chain reaction assays for carbapenemase-encoding genes. Laboratory challenges and the limited number of effective antimicrobial agents and the lack of pediatric-specific safety and efficacy data for these drugs are discussed.

Clinical Characteristics of Patients Who Test Positive for Clostridium difficile by Repeat PCR

ABSTRACT The high sensitivity of PCR assays for diagnosing Clostridium difficile infection (CDI) has greatly reduced the need for repeat testing after a negative result. Nevertheless, a small subset of patients do test positive within 7 days of a negative test. The aim of this study was to evaluate the clinical characteristics of these patients to determine when repeat testing may be appropriate. The results of all Xpert C. difficile PCR (Cepheid, Sunnyvale CA) tests performed in the clinical microbiology laboratory at New York-Presbyterian Hospital, Columbia University Medical Center (NYPH/CUMC) from 1 May 2011 through 6 September 2013, were reviewed. A retrospective case-control study was performed, comparing patients who tested positive within 7 days of a negative test result to a random selection of 50 controls who tested negative within 7 days of a negative test result. During the study period, a total of 14,875 tests were performed, of which 1,066 were repeat tests (7.2%). Eleven of these repeat tests results were positive (1.0%). The only risk factor independently associated with repeat testing positive was history of a prior CDI (odds ratio [OR], 19.6 [95% confidence interval {CI}, 4.0 to 19.5], P < 0.001). We found that patients who test positive for C. difficile by PCR within 7 days of a negative test are more likely to have a history of CDI than are patients who test negative with repeat PCR. This finding may be due to the high rate of disease relapse or the increased likelihood of empirical therapy leading to false-negative results in these patients.

Correlation between serum gastrin and cellular proliferation in Barrett’s esophagus

Background: Patients with Barrett’s esophagus (BE) are commonly treated with proton-pump inhibitors (PPIs) to minimize the exposure of esophageal mucosa to stomach acid. However, the use of these medications can lead to significant hypergastrinemia in a subset of patients, which is concerning due to the known tumorigenic and proliferative effects of gastrin. The present pilot study aims to investigate a potential correlation between serum gastrin and cellular proliferation in BE. Methods: We performed a cross-sectional analysis of patients with nondysplastic BE on PPI therapy. Fasting serum gastrin was measured on the same day as esophageal biopsies were obtained. These biopsies were then stained with Ki-67 nuclear antibody. Pearson’s correlation coefficient was calculated to assess the relationship between Ki-67 index and ln(gastrin). Results: A total of 10 patients were included in the study. The mean age was 62.6 (±8.4) years and 5 patients were male. The median serum gastrin level was 45.2 pM (interquartile range [IQR] 33–113) and the median Ki-67 index was 49.6% (IQR 23–64). We found a statistically significant positive correlation between Ki-67 index and ln(gastrin) (r = 0.64; p = 0.05). Conclusions: In nondysplastic BE patients on PPI therapy, serum gastrin levels were significantly correlated with cellular proliferation. These pilot data lend support to a potential causal effect of gastrin on neoplastic progression in BE. Longitudinal studies of patients with BE are needed to determine whether hypergastrinemia is a risk factor for the development of dysplasia and adenocarcinoma or could be used as a biomarker for disease progression.

Detection of mcr-1-Carrying Escherichia coli Causing Bloodstream Infection in a New York City Hospital: Avian Origins, Human Concerns?

Abstract The spread of mcr-1 in the United States remains poorly defined. mcr-1-producing Escherichia coli that also carried blaSHV-12 was detected in a hospitalized patient. No additional cases were identified during screening of 801 Gram-negative isolates. Genomic sequencing identified an IncX4 mcr-1- harboring plasmid and ST117 clonal background associated with avian pathogenic E coli.

Outbreak of Rapidly Growing Nontuberculous Mycobacteria Among Patients Undergoing Cosmetic Surgery in the Dominican Republic.

Rapidly growing nontuberculous mycobacteria (RG-NTM), which can contaminate inadequately sterilized medical instruments, have been known to cause serious postsurgical skin and soft tissue infections that often are characterized by a prolonged incubation period and a disfiguring clinical course. Historically, these infections have been associated with surgical procedures performed outside the United States. The Centers for Disease Control and Prevention recently reported an outbreak of RG-NTM infections among women who underwent cosmetic surgery in the Dominican Republic. Because of the large Dominican American community in upper Manhattan, we have recently observed a number of these cases at NewYork-Presbyterian Hospital/Columbia University Medical Center. We highlight the case of a 55-year-old woman who developed a postsurgical RG-NTM infection after bilateral breast reduction in the Dominican Republic; she experienced progressive deformity of her left breast until the causative pathogen was identified 20 months after her initial surgery. To assist in the timely diagnosis and treatment of these infections, we aim to promote greater awareness among physicians who are likely to encounter such patients. We present the pathologic findings of a review of 7 cases of RG-NTM infections seen at NewYork-Presbyterian Hospital/Columbia University Medical Center and discuss the diagnostic and therapeutic challenges associated with these infections, such as prolonged incubation periods, the need for acid-fast stains and mycobacterial cultures, and the combination of surgical therapy and lengthy antibiotic courses that are often required for treatment.

Diagnostic Endoscopic Mucosal Resection (EMR) Leads to a Change in Histologic Diagnosis in Barrett's Esophagus (BE) Patients With Visible and Flat Neoplasia

BACKGROUND: Radiofrequency ablation (RFA) is an endoscopic ablation modality used to treat Barretts esophagus (BE) with the goal of eliminating dysplasia and metaplasia. Factors associated with stricture formation or incomplete eradication of intestinal metaplasia (EIM) are poorly understood. AIM: To determine the factors associated with stricture formation or incomplete EIM. METHODS: This was a retrospective study of all patients treated with RFA for BE at a tertiary care referral center between June 2006 and November 2010. Pertinent information was extracted from medical records, including: demographics, history of BE (pre-ablation histology, duration of pre-treatment dysplasia), medication and substance use, indicators of GERD activity (symptoms, presence of erosive esophagitis), upper endoscopy findings (Prague criteria, hiatus hernia), ablation outcomes (elimination of metaplasia and dysplasia), and complications (perforation, stricture, bleeding, and hospitalization). Outcomes related to RFA were described for all patients as well as stratified by pre-ablation histology. Comparative analysis of patients with and without stricture and complete and incomplete elimination of dysplasia were performed with non-parametric tests (Fishers exact test for categorical data, Wilcoxon rank-sum test for continuous data) to determine associated factors. RESULTS: Among 113 patients who received RFA for BE (22 low-grade dysplasia, 77 high-grade dysplasia, 14 intramucosal carcinoma), 83 (73.5%) completed treatment with 95.2% complete elimination of dysplasia and 85.5% complete EIM. Of the remaining 30 subjects, 22 had ongoing treatment, 6 were lost to follow up, one had treatment delay for antireflux surgery and 1 opted for esophagectomy. Nine patients (8.0%) experienced a treatment-related complication, including8 strictures and 1 post-procedure hemorrhage. Stricture formation was associated with receiving endoscopic mucosal resection (75.0% vs. 36.2%, p=0.05) and number of EMR sessions (mean 1.4 vs. 0.4, p=0.007). A trend toward stricture formation existed with number of focal RFA treatments (mean 3.3 vs. 2.2, p=0.09), active NSAID use (75.0% vs. 44.8%, p=0.14) and prior peptic stricture (25.0% vs. 7.6%, p=0.15). Incomplete EIM was associated with ongoing GERD symptoms (75.0% vs. 33.8%, p=0.01) while increased Prague M length had a trend toward association (mean 6.6 vs. 4.5cm, p=0.11). CONCLUSIONS: RFA at a tertiary referral center is both safe (8.0% with complications, mostly benign strictures) and efficacious (95.2% elimination of dysplasia, 85.5% elimination of intestinal metaplasia). Previous EMR is associated with stricture formation while ongoing GERD symptoms are associated with incomplete elimination of intestinal metaplasia. These findings should be considered in planning treatment protocols for patients with BE.

Clinical Significance of Human Herpesvirus 6 Positivity on the FilmArray Meningitis/Encephalitis Panel

Abstract A review of 15 patients who tested positive for human herpesvirus 6 (HHV-6) on the FilmArray Meningitis/Encephalitis panel revealed that the majority were unlikely to have HHV-6 encephalitis. Criteria to assist interpretation of HHV-6 positive results are presented.

The Brief Case: Too Beta To Be a “B”

A 29-year-old African-American woman was seen in her third pregnancy. In her first pregnancy, she experienced preterm labor and premature rupture of membranes with delivery of a previable infant at 5 months. Her second pregnancy ended in spontaneous abortion at 7 weeks. Current other medical