Matthew J. Akiyama

Scedosporium apiospermum infections and the role of combination antifungal therapy and GM-CSF: A case report and review of the literature

Scedosporium apiospermum, a ubiquitous environmental mold, is increasingly reported as causing invasive fungal disease in immunocompromised hosts. It poses a therapeutic challenge due to its intrinsic resistance to traditional antifungals and ability to recur despite demonstrating susceptibility. We present an immunocompromised patient with a cutaneous S. apiospermum infection that disseminated despite treatment with voriconazole, the drug of choice. Adding echinocandins and GM-CSF provided partial recovery, indicating a potential synergistic role of dual-antifungal and immunotherapeutic agents.

The PREVAIL Study: intensive models of HCV care for people who inject drugs

Methods: PREVAIL is a randomized controlled trial that enrolled HCV-infected (genotype 1) PWID maintained on OAT, including those actively using drugs. Participants were randomized to one of three models of HCV care delivered on-site in an OAT program: 1) directly observed treatment (DOT), 2) group medical visit (Group), or 3) individual treatment as usual (TAU). Participants received DAAs according to AASLD guidelines: telaprevir/pegylated interferon/ribavirin (TVR/PEG/RBV), sofosbuvir/ribavirin (SOF/RBV), sofosbuvir/pegylated interferon/ribavirin (SOF/PEG/RBV), sofosbuvir/simeprevir (SOF/SMV), or sofosbuvir/ledipasvir (SOF/LDV). The primary outcome was SVR12 and secondary outcomes were end of treatment response (ETR) and SVR12. Drug use (opiates, cocaine, and benzodiazepines) was assessed through urine screens. Differences by arm were tested by a Fisher exact test, and the 95% confidence interval (CI) for virological outcomes were determined by the ClopperPearson method.

A quality improvement approach to capacity building in low- and middle-income countries.

Objectives:To describe the HEALTHQUAL framework consisting of the following three components: performance measurement, quality improvement and the quality management program, representing an adaptive approach to building capacity in national quality management programs in low and middle-income countries. Design:We present a case study from Namibia illustrating how this approach is adapted to country context. Methods:HEALTHQUAL partners with Ministries of Health to build knowledge and expertise in modern improvement methods, including data collection, analysis and reporting, process analysis and the use of data to implement quality improvement projects that aim to improve systems and processes of care. Clinical performance measures are selected in each country by the Ministry of Health on the basis of national guidelines. Patient records are sampled using a standardized statistical table to achieve a minimum confidence interval of 90%, with a spread of ±8% in participating facilities. Data are routinely reviewed to identify gaps in patient care, and aggregated to produce facility mean scores that are trended over time. A formal organizational assessment is conducted at facility and national levels to review the implementation progress. Results:Aggregate mean rates of performance for 10 of 11 indicators of HIV care improved for adult HIV-positive patients between 2008 and 2013. Conclusions:Quality improvement is an approach to capacity building and health systems strengthening that offers adaptive methodology. Synergistic implementation of elements of a national quality program can lead to improvements in care, in parallel with systematic capacity development for measurement, improvement and quality management throughout the healthcare delivery system.

Readmissions in HIV-infected inpatients: A large cohort analysis

Objective:Hospital readmissions impose considerable physical and psychological hardships on patients and represent a high, but possibly preventable, cost for insurers and hospitals alike. The objective of this study was to identify patient characteristics associated with 30-day readmission among persons living with HIV/AIDS (PLWH) using a statewide administrative database and to characterize the movement of patients between facilities. Design:Retrospective cohort analysis of HIV-infected individuals in New York State using a comprehensive, all-payer database. Setting:All hospitals in New York State. Participants:HIV-infected adults admitted to a medical service in 2012. PLWH identified using International Classification of Disease (ICD)-9 diagnosis codes 042 and V08. Results:Of 23,544 index hospitalizations, 21.8% (5121) resulted in readmission. Multivariable predictors of readmission included insurance status, housing instability, psychoses, multiple comorbid chronic conditions, substance use, and past inpatient and emergency department visits. Over 30% of readmissions occurred at a different facility than that of the initial hospitalization. Conclusion:A number of patient characteristics were independently associated with hospital readmission within 30 days. Behavioral health disorders and comorbid conditions may be the strongest predictors of readmission in PLWH. Readmissions, especially those in urban areas, often result in fragmented care which may compromise the quality of care and result in harmful discontinuity of medical treatment.

Correlates of Hepatitis C Virus Infection in the Targeted Testing Program of the New York City Jail System: Epidemiologic Patterns and Priorities for Action

Objective: The objective of this study was to understand predictors of hepatitis C virus (HCV) antibody positivity in a large urban jail system in New York City. Methods: We examined demographic characteristics, risk behaviors, and HCV antibody prevalence among 10 790 jail inmates aged 16 to 86 who were screened from June 13, 2013, to June 13, 2014, based on birth cohort or conventional high-risk criteria. We used logistic regression analysis to determine predictors of HCV antibody positivity. Results: Of the 10 790 inmates screened, 2221 (20.6%) were HCV antibody positive. In the multivariate analysis, HCV antibody positivity was associated most strongly with injection drug use (IDU; adjusted odds ratio [aOR] = 35.0; 95% confidence interval [CI], 28.5-43.0). Women were more likely than men to be infected with HCV (aOR = 1.3; 95% CI, 1.1-1.5). Compared with non-Hispanic black people, Hispanic (aOR = 2.1; 95% CI, 1.8-2.4) and non-Hispanic white (aOR = 1.7; 95% CI, 1.5-2.1) people were more likely to be infected with HCV. Non-IDU, recidivism, HIV infection, homelessness, mental illness, and lower education level were all significantly associated with HCV infection. The prevalence rate of HCV infection among a subset of inmates born after 1965 who denied IDU and were not infected with HIV was 5.6% (198 of 3529). Predictors of HCV infection among this group included non-IDU as well as being non-Hispanic white, Hispanic, recidivist, and homeless. Conclusion: These data reveal differences in HCV infection by sex, race/ethnicity, and socioeconomics in a large jail population, suggesting that a focused public health intervention is required and that universal screening may be warranted. Further sensitivity and cost-benefit analyses are needed to make this determination.

Feasibility of Treating Hepatitis C in a Transient Jail Population

Abstract Jails represent a critical component of the public health response to HCV elimination. We report on outcomes of 104 patients receiving HCV treatment from January 1, 2014 to June 30, 2016 in a large urban jail setting. Our data demonstrate that treatment in jails is feasible, but many barriers remain.

Rationale, design, and methodology of a trial evaluating three models of care for HCV treatment among injection drug users on opioid agonist therapy

BackgroundPeople who inject drugs (PWID) constitute 60% of the approximately 5 million people in the U.S. infected with hepatitis C virus (HCV). Treatment of PWID is complex due to addiction, mental illness, poverty, homelessness, lack of positive social support, poor adherence-related skills, low motivation and knowledge, and poor access to and trust in the health care system. New direct-acting antiviral medications are available for HCV with high cure rates and few side effects. The life expectancy and economic benefits of new HCV treatments will not be realized unless we determine optimal models of care for the majority of HCV-infected patients. The purpose of this study is to evaluate the effectiveness of directly observed therapy and group treatment compared with self-administered individual treatment in a large, urban opioid agonist therapy clinic setting in the Bronx, New York.Methods/designIn this randomized controlled trial 150 PWID with chronic HCV were recruited from opioid agonist treatment (OAT) clinics and randomized to one of three models of onsite HCV treatment in OAT: 1) modified directly observed therapy; 2) group treatment; or 3) control – self-administered individual treatment. Participants were age 18 or older, HCV genotype 1, English or Spanish speaking, treatment naïve (or treatment experienced after 12/3/14), willing to receive HCV treatment onsite, receiving methadone or buprenorphine at the medication window at least once per week, and able to provide informed consent. Outcomes of interest include adherence (as measured by self-report and electronic blister packs), HCV treatment completion, sustained virologic response, drug resistance, and cost-effectiveness.DiscussionThis paper describes the design and rationale of a randomized controlled trial comparing three models of care for HCV therapy delivered in an opioid agonist treatment program. Our trial will be critical to rigorously identify models of care that result in high adherence and cure rates. Use of blister pack technology will help us determine the role of adherence in successful cure of HCV. Moreover, the trial methodology outlined here can serve as a template for the development of future programs and studies among HCV-infected drug users receiving opioid agonist therapy, as well as the cost-effectiveness of such programs.Trial registrationThis trial was registered with ClinicalTrials.gov (NCT01857245). Trial registration was obtained prospectively on May 20th, 2013.

Treatment of Chronic Hepatitis C in Patients Receiving Opioid Agonist Therapy: A Review of Best Practice

Injection drug use is the most common transmission route for hepatitis C. High rates of infection are observed among individuals on opioid agonist therapy. Although people who inject drugs carry the highest burden, few have initiated treatment. We present a comprehensive review of the evidence on the efficacy of HCV medications, drug-drug interactions, and barriers to and models of care. Studies have demonstrated comparable efficacy for individuals who are on opioid agonist therapy compared with those who are not. We propose that a strategy of treatment and cure-as-prevention is imperative in this population to curb the hepatitis C epidemic.

Human Strongyloidiasis in Hawaii: A Retrospective Review of Enzyme-Linked Immunosorbent Assay Serodiagnostic Testing

Human strongyloidiasis is widely prevalent in tropical and subtropical regions worldwide but is not endemic in Hawaii. Subclinical, chronic infections may be lifelong; immunosuppressive therapy, particularly with glucocorticoids, may lead to serious or fatal disseminated disease, which is preventable. We performed a retrospective analysis of patients tested for Strongyloides immunoglobulin G antibody in an academic medical center in Honolulu, Hawaii, from 2005 to 2012. Of the 475 patients tested, 78 (16%) were seropositive. The largest proportion of seropositive cases was found among Micronesians (30%), Polynesians (26%), Filipinos (13%), and Southeast Asians (11%). Among the seropositive patients, the most likely reason for clinicians to order testing was blood eosinophilia. Stool parasite examination results were available for 58% of seropositive patients of which 11% were positive for Strongyloides stercoralis larvae. Antihelminthic therapy, usually ivermectin, was ordered for 71% of patients. After treatment, blood eosinophilia and Strongyloides serology results were reassessed for 76% and 35% of patients, respectively; both tests tended to show improvement. Travelers and immigrants from Strongyloides-endemic areas, including Micronesia and Polynesia, should have serodiagnostic testing for latent strongyloidiasis, and if positive, treated empirically with ivermectin, particularly when corticosteroids or other immunosuppressive therapies are anticipated.

Drug Purchasing Strategies to Treat People With Hepatitis C in the Criminal Justice System

The authors offer their thoughts on a strategy for purchasing drugs to treat Hepatitis C (HCV) patients in the U.S. criminal justice system. They discuss how failure to properly treat incarcerated individuals with HCV can lead to further medical complications, disease transmission, or death. To address the costs of drugs, the authors suggest that correctional institutes partner with 340B safety-net providers or state Medicaid programs.