Impact of COVID-19 on pediatric asthma-related healthcare utilization in New York City: a community-based study.

BACKGROUND: COVID-19 disproportionately affects families of low socioeconomic status and may worsen health disparities that existed prior to the pandemic. Asthma is a common chronic disease in children exacerbated by environmental exposures. METHODS: A cross-sectional survey was conducted to understand the impact of the initial stage of the pandemic on environmental and social conditions, along with access to care for children with asthma in New York City (NYC). Participants were recruited from a community-based organization in East Harlem and a nearby academic Pediatric Pulmonary clinic and categorized as having either public or private insurance (n = 51). RESULTS: Factors significantly associated with public compared to private insurance respectively were: increased reports of indoor asthma triggers (cockroach 76% vs 23%; mold 40% vs 12%), reduced income (72% vs 27%), and housing insecurity (32% vs 0%). Participants with public insurance were more likely to experience conditions less conducive to social distancing compared to respondents with private insurance, such as remaining in NYC (92% vs 38%) and using public transportation (44% vs 4%); families with private insurance also had greater access to remote work (81% vs 8%). Families with public insurance were significantly more likely to test positive for SARS-CoV-2 (48% vs 15%) but less likely to have gotten tested (76% vs 100%). Families with public insurance also reported greater challenges accessing office medical care and less access to telehealth, although not statistically significant (44% vs 19%; 68% vs 85%, respectively). CONCLUSIONS: Findings highlight disproportionate burdens of the pandemic, and how these disparities affect children with asthma in urban environments.

Patient perspectives on penicillin allergy and testing.

Background: Most patients who report penicillin allergy are found to tolerate penicillin later in life. Few studies have examined patients' understanding and beliefs about penicillin allergy and testing. Evaluating patients' perspectives may help identify ways to improve patient education and increase testing to de-label those who can tolerate penicillin. Objective: To better understand patient perspectives on penicillin allergy testing and to identify whether patient characteristics and beliefs impact completion of testing. Methods: Patients who were visiting our allergy clinics and had documentation of a penicillin allergy in the electronic medical record (EMR) were approached to complete a survey with regard to their reaction history and knowledge and/or perspectives about penicillin allergy and testing. Eighty-eight patients completed the survey, and their medical records were reviewed to collect results of penicillin testing. Results: Fewer than half of the patients (45.5%) who had EMR-documented penicillin allergy reported awareness that testing for penicillin allergy is available. Awareness of penicillin allergy testing was significantly associated with completion of testing, whereas other patient characteristics, such as education, income, and distance to the hospital, were not. Patients who scheduled a return visit for testing at the time of their initial visit were significantly more likely to follow through with testing. Most patients were interested in penicillin testing. For patients who were not interested, the most frequently cited reason was fear of adverse effects of testing. Conclusion: Among the patients who carried a penicillin allergy label, those who were aware of penicillin allergy testing were more likely to complete testing, and ease of scheduling contributed to higher rates of testing completion. Fear about adverse effects from testing was the most reported barrier. Our findings emphasized the importance of increasing awareness of the availability and safety of penicillin testing through patient education and collaboration with other specialties.

Environmental exposures: evolving evidence for their roles in adult allergic disorders.

PURPOSE OF REVIEW: Allergic disorders are the result of complex interactions between genetic predisposition and environmental exposures. Elucidating how specific environmental exposures contribute to allergic diseases in adults is crucial, especially as the world population ages in a rapidly changing environment. RECENT FINDINGS: The effects of environmental exposures on allergic diseases remain understudied in adults. Although epidemiological studies suggest various environmental exposures are associated with the development and exacerbation of allergic diseases, further longitudinal studies are needed across various age groups in adults to pinpoint the exposures of concerns and the time windows of susceptibility. Mechanistic studies in adults are few. A multicomponent strategy targeting several allergens has been conditionally recommended for asthma, but recent findings on mitigation strategies remain limited. SUMMARY: Further research on how environmental exposures cause and exacerbate allergic disorders is needed in adults, particularly across disease phenotypes. The effects of mitigation strategies against environmentally induced adult allergic diseases remain large research gaps. A better understanding of how and which environmental exposures contribute to allergic disorders is necessary to identify patients who are at higher risk and would benefit from specific interventions.

COVID-19 prevalence and outcomes in patients receiving biologic therapies at an infusion center in New York City.

To better understand COVID-19 infection in patients receiving biologic and immunomodulatory therapies, we evaluated prevalence and outcomes for symptomatic cases of COVID-19 at a large therapeutic infusion center in New York City during the height of the pandemic. 2074 patients received treatment with biologic infusions at our center between March and May 2020, and 34 patients developed symptomatic COVID-19 infection, for an overall low rate of 1.64%. The majority of infections and deaths were in a small subset of patients with a primary immunodeficiency. Patients with inflammatory or autoimmune conditions requiring biologic therapies tended to have mild cases. Higher inflammatory responses were observed in patients who died.

A 79-year-old man with persistent eosinophilia and elevated immunoglobulin E.

The differential diagnoses for eosinophilia include allergic, infectious, autoimmune, and neoplastic diseases. We presented the case of a 79-year-old man with eosinophilia and elevated immunoglobulin E that persisted despite adequate treatment for possible environmental exposures. Further specialized testing based on his initial workup led to his diagnosis. This case highlights the importance of sequential and targeted testing to evaluate for rare causes of eosinophilia.

Native Joint Septic Arthritis: Comparison of Outcomes with Medical and Surgical Management.

OBJECTIVE: To determine whether there are differences in the outcomes of native joint septic arthritis (SA) in adults, based on medical versus surgical management. METHODS: A 10-year retrospective single-center study was conducted of patients admitted to a tertiary care hospital between January 1, 2006 and December 31, 2015 with a diagnosis of SA to compare outcomes based on the management approach taken: medical (bedside closed-needle joint aspiration) versus surgical (arthrotomy/arthroscopy). Evaluated outcomes included joint recovery, time to recovery, length of stay, disposition to home versus rehabilitation unit, recurrence of SA in the same joint, and mortality. RESULTS: Of 118 confirmed cases of SA, 48 were in prosthetic joints and 70 were in native joints, and 61 met our inclusion criteria. Forty-one (67%) patients received surgery, and 20 (33%) received closed-needle aspiration. There was no statistically significant difference in long-term outcomes between the two groups at 12 months. Patients managed medically were more likely to experience full recovery at 3 months and were less likely to need short-term rehabilitation. CONCLUSIONS: Medical management with closed-needle aspiration may be an adequate approach to the treatment of native joint infections.

Paradoxical Reaction in a Patient with Co-Occurring Tuberculous Meningitis and Pott's Disease.

BACKGROUND Paradoxical reactions to tuberculosis (TB) are clinical or radiological worsening of prior tuberculous lesions or the development of new lesions upon treatment with appropriate anti-tuberculosis therapy (ATT). This phenomenon has been described in both HIV-seropositive and HIV-seronegative patients. Although historically estimated to occur in 6-30% of HIV-seronegative patients with TB, the phenomenon is often under-recognized in the current era, particularly in countries of low TB prevalence. We describe a case of a TB paradoxical reaction affecting the CNS and spine in an HIV-seronegative individual who received clinical care in the U.S. CASE REPORT A 36-year-old HIV-seronegative refugee from Eritrea presented to the hospital with fever, back pain, and headache shortly after arriving to the U.S. He was diagnosed with TB meningitis and Pott's disease and was started on ATT. He developed worsening clinical symptoms, including headaches, transient diplopia, and mood disturbances, as well as new radiologic abnormalities in the brain (tuberculomas) and spine (abnormal enhancement) despite appropriate ATT. He received prolonged 4-drug ATT and steroids as well as changes in his ATT regimen, and multiple attempts were made to biopsy the brain and spine to address concerns for radiologic changes. Eventually, he was discharged 1 year later with clinical improvement and full neurologic recovery. CONCLUSIONS Radiologic and clinical findings due to paradoxical reactions may be unfamiliar to clinicians in countries with low TB prevalence and inadvertently lead to either inadequate management such as the underappreciation of the clinical signs and symptoms indicating potential severity of CNS paradoxical reaction, or conversely overly invasive approaches in a patient who is otherwise clinically improving. Increasing awareness about extrapulmonary paradoxical reactions in such patients is crucial for ensuring appropriate diagnostic approaches and timely clinical management.

Zoster vaccine-associated primary varicella infection in an immunocompetent host.

A 64-year-old immunocompetent man developed a widespread pruritic and vesicular rash 2 weeks after receiving the zoster vaccine (Zostavax). He had fever, bandaemia with normal total white blood cell count and mild transaminitis. PCR testing of serum and skin was positive for varicella zoster virus (VZV), while serum VZV IgG was negative. The analysis of single nucleotide polymorphism by PCR and sequencing from the skin swab was consistent with the vaccine strain. The patient received 1 week of intravenous acyclovir and was discharged after all lesions had crusted. He continues to do well on follow-up with no significant complications.

Nicotinic acid modulates Legionella pneumophila gene expression and induces virulence traits.

In response to environmental fluctuations or stresses, bacteria can activate transcriptional and phenotypic programs to coordinate an adaptive response. The intracellular pathogen Legionella pneumophila converts from a noninfectious replicative form to an infectious transmissive form when the bacterium encounters alterations in either amino acid concentrations or fatty acid biosynthesis. Here, we report that L. pneumophila differentiation is also triggered by nicotinic acid, a precursor of the central metabolite NAD(+). In particular, when replicative L. pneumophila are treated with 5 mM nicotinic acid, the bacteria induce numerous transmissive-phase phenotypes, including motility, cytotoxicity toward macrophages, sodium sensitivity, and lysosome avoidance. Transcriptional profile analysis determined that nicotinic acid induces the expression of a panel of genes characteristic of transmissive-phase L. pneumophila. Moreover, an additional 213 genes specific to nicotinic acid treatment were altered. Although nearly 25% of these genes lack an assigned function, the gene most highly induced by nicotinic acid treatment encodes a putative major facilitator superfamily transporter, Lpg0273. Indeed, lpg0273 protects L. pneumophila from toxic concentrations of nicotinic acid as judged by analyzing the growth of the corresponding mutant. The broad utility of the nicotinic acid pathway to couple central metabolism and cell fate is underscored by this small metabolite's modulation of gene expression by diverse microbes, including Candida glabrata, Bordetella pertussis, Escherichia coli, and L. pneumophila.

Efficient generation of unmarked deletions in Legionella pneumophila.

Unmarked gene deletions facilitate studies of Legionella pneumophila multicomponent processes, such as motility and exonuclease activity. For this purpose, FRT-flanked alleles constructed in Escherichia coli using λ-Red recombinase were transferred to L. pneumophila by natural transformation. Resistance cassettes were then efficiently excised using the Flp site-specific recombinase encoded on a plasmid that is readily lost.