Rodriguez-Gutierrez R, McCoy RG.

This Viewpoint discusses the inadequacy of hemoglobin A1c levels as a marker of effects of treatment on clinically important diabetes outcomes, and argues for replacing it with measures of treatment effects important to patients and their caregivers, such as hyperglycemia and hypoglycemia, vision deterioration, neuropathy and ulceration, diabetes distress, and treatment-related financial hardship.

Rolfes M, Flannery B, Patel M, et al.

Gregg EW, Hora I, Benoit SR.

In this Viewpoint, CDC authors discuss possible mechanisms behind apparent increases in lower-extremity amputations, hyperglycemic emergencies, and heart disease among patients with diabetes between 2010 and 2015, including a changing profile of the population of new diabetes cases, stagnation in preventive care, insurance factors discouraging access, or broader economic factors that may adversely influence vulnerable populations.

Abstract Background Understanding the underlying epidemiology that shapes Neisseria gonorrhoeae (GC), and Chlamydia trachomatis (CT) infections can contribute to data driven policies directed towards curbing the proliferation of these pathogens in Ghana. Information on the symptoms and risk factors for STIs will help to identify high-risk individuals which will in turn inform STI syndromic management and tailor the use of public health resources. Methods Participants were from 4 military clinics and 1 civilian STI clinic in Ghana and eligible if they had symptoms suggestive of STI. First void urine samples were collected and tested with Nucleic Acid Amplification Test (NAAT). A structured questionnaire was administered to all participants. Multivariate logistic regression identified factors associated with infection, separately for NG and for CT and for men and women. Results A total of 950 patients, 58% of whom were females were enrolled, 28% had gonorrhea and 11% had chlamydia with more males testing positive than females. Reported symptoms that were more common among patients who tested positive for gonorrhea were painful urination and urethral discharge (all P values

Abstract Malaria control and preventive activities in the countries of the World Health Organization Region for Europe (WHO/EUR) were strengthened within the framework of the Regional Roll Back Malaria strategy adopted by the member-states at the beginning of the 2000s. A political document “From control to malaria elimination” known as the “Tashkent Declaration” was unanimously endorsed by the member-states of the WHO/EUR with malaria problems in 2005. Since then, considerable progress has been achieved in the countries of the region, signified by the dramatic reduction of malaria incidence in conjunction with the prevention of re-establishment of infection on the territories where malaria was eliminated earlier. Several countries of the region had been certified by the WHO as free of local malaria transmission as a result of the activities of their National Malaria Elimination Programme, Armenia being one of the first in 2011. One of the main lessons learnt during the implementation of the activities by the National Malaria Elimination Programme in Armenia was that the development of an operational plan for malaria elimination required a comprehensive national effort. Full support, both political and financial, from the highest levels of government to smooth coordination between different government ministries, such as Agriculture, Defense, Finance, Health and Policy and Planning and others, was a prerequisite for operational success. The role and place of various partners in the achievement of malaria elimination in the country is discussed in this review.…

Steurer-Stey C.

To the Editor The randomized clinical trial by Dr Aboumatar and colleagues demonstrated that the combination of transitional care support and long-term self-management resulted in fewer hospitalizations and emergency department visits for patients with chronic obstructive pulmonary disease (COPD). One statement in the article deserves a comment.

Aboumatar H, Wise RA.

In Reply We agree with Dr Steurer-Stey that the use of action plans with adequate instructions for self-medication can be helpful for the management of some patients with COPD. However, this approach needs to be individualized and consider patient factors such as comorbidities, cognitive status, and knowledge. As Fan et al pointed out, self-medication may not be helpful for all patients, and the authors of the recent Cochrane review recommended taking into account comorbidities in self-management action plans.

Abstract Background The emergence of leptospirosis-associated severe pulmonary hemorrhagic syndrome (SPHS) with high case fatality has been reported from many countries. Understanding of clinical disease and sequel of SPHS needs larger studies with adequate numbers. The purpose of this study was to describe the characteristics and sequel by different therapeutic approaches for SPHS in Leptospirosis in Sri Lanka. Methods This study was conducted at Teaching Hospital-Karapitiya (THK), Galle, Sri Lanka from June 2015 to December 2017. THK is the main tertiary care center for the Southern Province. All confirmed-cases of leptospirosis who presented during this period and were admitted to five medical units of THK were included in this study. SPHS was defined as a patient presenting; haemoptysis, arterial hypoxemia (Acute Lung Injury Score 

Abstract Background Brucellosis is an infectious zoonotic disease and is common especially among pastoral communities in most low and middle-income countries. The aim of this study was to determine sero-prevalence, and risk factors of Brucella infection among Slaughterhouse workers, in Bahr el Ghazal region, South Sudan. Methods A cross sectional study was conducted among Slaughterhouse workers in Bahr el Ghazal region, South Sudan from December 2015 to May 2016. A pre-tested questionnaire was used in data collection. Each randomly selected participant was interviewed and a venous blood sample collected. The blood samples were screened for Brucellosis infection using Rose Bengal Plate Test (RBPT) and confirmed using Competitive Enzyme link Immuno Sorbet Assay (c-ELISA). Data was analyzed using Stata version 13 at 95% level of confidence. Results A total of 234 Slaughterhouse workers were screen for Brucella infection. Overall, a third, 32.1% (75/234) of the participants were sero-positive for brucellosis. The prevalence of brucellosis was higher, 17.1% (40/234) in Wau state compared to other states. There was high prevalence among males, 28.6% (67/234) compared to females 3.4% (8/234). The mean age of study participants was 34.4 ± 9.6 years. A high proportion, 12.8% (30/234) of participants with confirmed brucellosis infection were 31–40 years of age. Brucellosis prevalence was high among butchers, 14.5% (34/234), and meat handlers, 9.0% (21/234). Conclusions Brucellosis is common among animal slaughterhouse workers in Bahr el Ghazal region, South Sudan. There is need for public awareness campaigns and educational programs to help sensitize communities on Brucella infection.…

Abstract Background Hepatitis A Virus (HAV) is one of the most common food and water borne infectious disease prevailing globally. The objective of the study was to determine sero-prevalence of HAV infection in a district of Sri Lanka. Methods This was a descriptive cross sectional study conducted on 1403 participants aged 1 year and above selected by multistage stratified (for age group and area of residence) cluster sampling from September 2015 to December, 2016. An interviewer-administered questionnaire was used to collect data and Anti-IgG testing was done to determine sero-positivity. The overall, the age and sex specific sero-prevalence of HAV were calculated with 95% confidence intervals (CI). Results Of the 1403 participants 1132 were anti HAV IgG positive. Therefore the overall sero-prevalence of HAV infection was 80.7% (95%CI: 78.64–82.76). There were 283 (20.2%) individuals below the age group of 14 years and below and out of them, 204 had anti HAV IgG, therefore sero-prevalence was 72.1% for that age group. The age group 15 years and aboe comprised of 1120 (79.8%) participants and of them 928 had anti HAV IgG, making sero-prevalence 82.9%. The lowest sero-prevalence (66.9%, n = 232) was observed in the age group of 11–20 years followed by 21–30 age group. From age 31 years onwards, the sero-prevalence exceeded 90%, reaching 100% after 71 years. The urban population showed a sero-prevalence of 83% (n = 195) and 80.2% (n = 937) for the rural sector while females had a sero-prevalence of 82.2% (n = 766) and it was 77.7% (n = 366) for males. Thirty-four (3.0%) participants who had sero-positive results (n = 1132) claimed that they have had HAV in the past. Conclusions Overall, four fifth of the population was immune to HAV infection in the district of Gampaha.…

Abstract Background Despite the undeniable significance of blood transfusion in saving a millions life in emergencies and medical treatment, the quality of blood faced challenges from transfusion-transmitted infections (TTIs) such as HIV (human immunodeficiency virus), HBV (hepatitis B virus) and HCV (hepatitis C virus). This cross-sectional study was undertaken with the aim of determining the seroprevalence and risk factors of HIV, HBV, and HCV among blood donors. Methods An institutional based cross-sectional study was conducted at Debre Tabor district hospital from January 2017 to February 2018. Blood samples from volunteer donors collected; serum separated and screened with ELISA tests for detection of anti-HIV, hepatitis-B surface antigen (HBsAg) and anti-HCV. Fishers’ exact test was employed to see the association between variables as well logistic regression tests were applied to identify potential risk factors. P-value of less than 0.05 was considered as statistically significant. Result A total of 310 volunteer donors were included in the study. The proportion of blood donors having at least one viral-TTI was 12.6% while the magnitudes of HIV, HBV, and HCV were 2.6, 5.8 and 4.2%, respectively. Educational status and multiple sexual behaviors are significantly associated with HIV acquisition whilst marital status was significantly associated with HBsAg seropositivity. Conclusion Seroprevalence of transfusion-transmissible infections was high and alarming therefore proper screening of donated blood with test methods having better diagnostic performance should be employed. Also encouragement of blood donation from voluntary donors and creating awareness on the general public regarding HIV, HBsAg and HCV transmission and prevention should be strengthen.…

Abstract Background São José do Rio Preto is one of the cities of the state of São Paulo, Brazil, that is hyperendemic for dengue, with the presence of the four dengue serotypes. Objectives: to calculate dengue seroprevalence in a neighbourhood of São José do Rio Preto and identify if socioeconomic and demographic covariates are associated with dengue seropositivity. Methods A cohort study to evaluate dengue seroprevalence and incidence and associated factors on people aged 10 years or older, was assembled in Vila Toninho neighbourhood, São José do Rio Preto. The participant enrolment occurred from October 2015 to March 2016 (the first wave of the cohort study), when blood samples were collected for serological test (ELISA IgG anti-DENV) and questionnaires were administrated on socio-demographic variables. We evaluated the data collected in this first wave using a cross-sectional design. We considered seropositive the participants that were positive in the serological test (seronegative otherwise). We modelled the seroprevalence with a logistic regression in a geostatistical approach. The Bayesian inference was made using integrated nested Laplace approximations (INLA) coupled with the Stochastic Partial Differential Equation method (SPDE). Results We found 986 seropositive individuals for DENV in 1322 individuals surveyed in the study area in the first wave of the cohort study, corresponding to a seroprevalence of 74.6% (95%CI: 72.2–76.9). Between the population that said never had dengue fever, 68.4% (566/828) were dengue seropositive. Older people, non-white and living in a house (instead of in an apartment), were positively associated with dengue seropositivity. We adjusted for the other socioeconomic and demographic covariates, and accounted for residual spatial dependence between observations, which was found to present up to 800 m. Conclusions Only one in four people aged 10 years or older did not have contact with any of the serotypes of dengue virus in Vila Toninho neighbourhood in São José do Rio Preto. Age, race and type of house were associated with the occurrence of the disease. The use of INLA in a geostatistical approach in a Bayesian context allowed us to take into account the spatial dependence between the observations and identify the associated covariates to dengue seroprevalence.…

Langereis, J. D., van der Pasch, E. S., de Jonge, M. I.

Non-typeable Haemophilus influenzae (NTHi) colonizes the human upper respiratory tract without causing disease symptoms, but it is also a major cause of upper and lower respiratory tract infections in children and elderly, respectively.NTHi synthesizes various molecules to decorate its lipooligosaccharide (LOS) that modulates the level of virulence. The presence of phosphorylcholine (PCho) on NTHi LOS increases adhesion to epithelial cells, which is an advantage for the bacterium enabling nasopharyngeal colonization. However, when PCho is incorporated on the LOS of NTHi, it is recognized by the acute phase protein C-reactive protein (CRP) and PCho-specific antibodies, both potent initiators of the classical pathway of complement activation.We determined the presence of PCho and binding of IgG and IgM to the bacterial surface for 319 NTHi strains collected from the nasopharynx/oropharynx, middle ear and lower respiratory tract. PCho detection was higher for NTHi strains collected from the nasopharynx/oropharynx, which was associated with increased binding of IgM and IgG to the bacterial surface. Binding of CRP and IgM to the bacterial surface of a PChohigh NTHi increased complement-mediated killing, which was largely dependent on PCho-specific IgM. The levels of PCho-specific IgM varied in serum from 12 healthy individuals and higher PCho-specific IgM levels were associated with increased complement-mediated killing of a PChohigh NTHi strain.In conclusion, incorporation of PCho on the LOS of NTHi marks the bacterium for binding of CRP and IgM resulting in complement-mediated killing. Therefore, having lower PCho might be beneficial in situations where sufficient PCho-specific antibodies and complement are present.…

George M. Varghese, Vijay Prakash Turaka, Jeshina Janardhanan, Sadhana Yadav, Kavitha M. Lakshmi, Vijayakumar TS, Bobby Cherayil

Tuberculosis (TB) continues to be a significant cause of morbidity and mortality worldwide. The recent annual report on TB by the World Health Organization (WHO) estimated 10 million new and recurrent TB cases globally, with India alone accounting for 27% of these cases, causing 1.3 million and 300,000 deaths in HIV negative and HIV positive individuals respectively (WHO, 2018). The progression from uninfected or latently infected to active tuberculosis is often insidious and has minimal symptoms in the initial months, resulting in delayed diagnosis and poor outcomes (Lui et al., 2014).

Friedrich MJ.

Women in Africa are 50 times more likely to die as a result of a cesarean delivery as women in high-income countries, a team of investigators from several African countries has reported. Neonates fare poorly, too. Their mortality rate after cesarean delivery is high—44 per 1000 live births.

Hongjo Choi, Haejoo Chung, Carles Muntaner

by Hongjo Choi, Haejoo Chung, Carles Muntaner The perspectives of social selection and causation have long been debated. Social selection theory is as “social” as social causation theory, since all diseases are social and no biological process occurs outside society. To identify the social selection pathway and historical juncture affected by socioeconomic and political changes, we investigated the reciprocal impact of suffering from tuberculosis (TB) on the current socioeconomic position (SEP), stratified by childhood SEP. We also examined the extent to which the social consequences of ill health changed since the East Asian economic downturn. Data were collected for 2007–2012 from the Korea National Health and Nutritional Examination Survey. To identify associations between TB history and current household income (HHI), we constructed an ordinal logistic regression model adjusted for covariates, including age, gender, educational attainment, and job status. We adopted a recursive regression model to examine trend changes in this association from 1980–2012 to 2003–2012. Of 28,136 participants, 936 had experienced TB. In the first ordinal logistic regression, the TB group was more likely to have lower HHI than the non-TB group. The odds ratios (ORs) increased from 1.30 (1980–2012) to 1.86 (2003–2012) for the TB group, increasing their probability of having low HHI. Among the low childhood SEP group, the TB group’s probability of having low HHI was 1.35 (95% confidence interval [CI]: 1.16–1.57) during 1980–2012, which increased to 2.01 (95% CI: 1.37–2.95) during 2003–2012. For the high childhood SEP group, the TB group’s OR range fluctuated, similar to that for the non-TB group. The results support the social selection pathway from TB history to adverse impact on current SEP. Our study identified downward social mobility due to TB history among the low childhood SEP group. Moreover, negative social consequences deteriorated since the East Asian economic crisis.

Abstract Background Pasteurella multocida (P. multocida) forms part of the normal flora of many animals. Although it is a common causative agent of skin and soft tissue infection after an animal bite or scratch, in rare cases it can cause spinal infections in humans. Case presentation A 68-year-old immunocompetent woman presented with fever and sudden onset of severe back pain mimicking aortic dissection. No findings related to the pain were revealed on enhanced computed tomography or initial magnetic resonance imaging (MRI) of the spine. The patient was found to be bacteremic with P. multocida, although she had no apparent injury related to animal contact. Repeated evaluation by MRI with gadolinium-contrast established the diagnosis of spinal epidural abscess. The patient was cured by the rapid initiation of antimicrobial therapy without surgery. Conclusions We describe the successful treatment of an individual with a spinal epidural abscess due to P. multocida without surgery. P. multocida infections may occur as sudden presentations. Obtaining the patient history of recent animal contact is essential. Repeated MRI evaluation may be required when spinal infections are suspected. To the best of our knowledge, this is the first report which describes a case of spinal epidural abscess due to this organism.…

Goering, R. V., Swartzendruber, E. A., Obradovich, A. E., Tickler, I. A., Tenover, F. C.

Staphylococcus aureus strains that possess a mecA gene but are phenotypically susceptible to oxacillin and cefoxitin (OS-MRSA) have been recognized for over a decade and are a challenge for diagnostic laboratories. The mechanisms underlying the discrepancy vary from isolate to isolate. We characterized seven OS-MRSA clinical isolates of six different spa types from six different states by whole genome sequencing (WGS) to identify the nucleotide sequence changes leading to the OS-MRSA phenotype. The results demonstrated that oxacillin susceptibility was associated with mutations in regions of nucleotide repeats within mecA. Subinhibitory antibiotic exposure selected for secondary mecA mutations that restored oxacillin resistance. Thus, strains of S. aureus that contain mecA but are phenotypically susceptible can become resistant after antibiotic exposure, which may result in treatment failure. OS-MRSA warrant follow-up susceptibility testing to insure detection of resistant revertants.…

Abstract Introduction We describe the use of bacteriophage therapy in a 26-year-old cystic fibrosis (CF) patient awaiting lung transplantation. Hospital Course The patient developed multidrug resistant (MDR) Pseudomonas aeruginosa pneumonia, persistent respiratory failure, and colistin-induced renal failure. We describe the use of intravenous bacteriophage therapy (BT) along with systemic antibiotics in this patient, lack of adverse events, and clinical resolution of infection with this approach. She did not have recurrence of pseudomonal pneumonia and CF exacerbation within 100 days following the end of BT and underwent successful bilateral lung transplantation 9 months later. Conclusion Given the concern for MDR P. aeruginosa infections in CF patients, BT may offer a viable anti-infective adjunct to traditional antibiotic therapy.…

Story-Roller, E., Maggioncalda, E. C., Lamichhane, G.

Mycobacterium abscessus is an emerging pathogen capable of causing invasive pulmonary infections in patients with chronic lung diseases. These infections are difficult to treat, necessitating prolonged multidrug therapy, which is further complicated by extensive intrinsic and acquired resistance exhibited by clinical M. abscessus isolates. Therefore, development of novel treatment regimens effective against drug-resistant strains is crucial. Prior studies have demonstrated synergistic efficacy of several β-lactams against M. abscessus in vitro; however, these combinations have never been tested in an animal model of M. abscessus pulmonary disease. We utilized a recently developed murine system of sustained M. abscessus lung infection delivered via aerosol route to test the bactericidal efficacy of four novel dual β-lactam combinations and one β-lactam/β-lactamase inhibitor combination. All five of the novel combinations exhibited synergy and resulted in at least six log10 reductions in bacterial burden in the lungs of mice at four weeks compared to untreated controls (p = 0.038).…

Stecher M, Claßen A, Klein F, et al.

AbstractBackgroundSafety and tolerability of analytical treatment interruptions (ATIs) as a vital part of HIV-1 cure studies are discussed. We analyzed current evidence for occurrence of adverse events (AEs) during treatment interruptions (TIs).MethodsOur analysis included studies reporting on AEs in HIV-1 infected patients undergoing TIs (including ATIs and structured TIs). All interventional and observational studies were reviewed and results extracted based on predefined criteria. Proportion of total AEs were pooled using random-effect models. A meta-regression model was calculated to explore the influence of baseline CD4+ T-cell count, viral load, study type, previous time on combined antiretroviral therapy (cART), and follow-up interval during TIs.ResultsWe identified 1,048 studies, of which 22 studies including 7,104 individuals fulfilled the defined selection criteria. Included studies showed sample sizes between six and 5,472 subjects, with durations of TI cycles ranging from seven days to 27 months. Intervals of HIV-1-RNA testing varied from two days up to three months during TIs. The overall proportion of AEs during TIs >4 weeks was 3% (95% CI 0%-7%), and was lower in studies with follow-up intervals ≤14 days (0%; 95% CI 0%-1%) than in studies with wider follow-up intervals (6%; 95% CI 2%-13%; p-value for interaction=0.01).ConclusionWe found moderate quality evidence indicating that studies with narrow follow-up intervals did not show a substantial increase of AEs during TIs. Our findings indicate that ATI may be a safe strategy as part of HIV-1 cure trials by closely monitoring for HIV-1 rebound during follow-up.

Farrell CM.

In this narrative medicine essay, a physician finds in the motion of diastole, the process of letting go and filling up, an apt metaphor for how to handle the burnout, anxiety, and depression of medical training.

Hadziabdic, S., Fischer, J., Borowiak, M., Malorny, B., Juraschek, K., Kaesbohrer, A., Guerra, B., Deneke, C., Gonzalez-Zorn, B., Szabo, I.

In 2012, a carbapenemase-producing Salmonella (S.) Corvallis carrying a blaNDM-1 multi-resistance IncA/C2 plasmid, apart from IncHI2 and ColE-like plasmids, was detected in a wild bird in Germany. In recent broiler chicken infection study, we observed transfer of this blaNDM-1-carrying IncA/C2 plasmid to other Enterobacteriaceae. Here, we focused on the stability of this plasmid and gained insight into type and frequency of its structural alterations after an in vivo passage in a broiler infection study. …

Abstract Background The fight against malaria faces various biological obstacles, including the resistance of parasites to anti-malarial drugs and the resistance of mosquito vectors to insecticides. The resistance of Anopheles gambiae sensu lato (s.l.) to pyrethroids, the only class of insecticides used to impregnate mosquito nets, is known in Benin; the expansion of this resistance is influenced by the existence of gene flow between species, otherwise by the presence or absence of the kdr mutation in them. The objective of this study is to determine the spatial distribution of An. gambiae and the level of expression of the pyrethroid resistance kdr gene in seven agro-ecological zones of Benin. Methods The study was conducted in 18 localities belonging to seven agro-ecological zones where environmental parameters varied. The sites represent the main areas of eco-epidemiological malaria in Benin. Anopheles gambiae larvae were collected in natural breeding sites using ladles and dipping method and reared under standard conditions. These larvae were reared under standard conditions of temperature and humidity (26 to 30 °C and 60 to 90%) at the insectarium of the Centre de Recherche Entomologique de Cotonou (CREC). Adult female mosquitoes having emerged are morphologically and molecularly identified. Homozygous resistant (1014F/1014F), homozygous sensitive (1014L/1014L) and heterozygous (1014F/1014L) genotypes of the L1014F kdr gene mutation are determined by PCR. Results A total of 677 An. gambiae was subjected at the PCR. The results revealed the presence of three vector species of the An. gambiae complex, of which 409 Anopheles coluzzii, 259 An. gambiae, 5 hybrids (An. coluzzii/An. gambiae) and 4 Anopheles arabiensis in the different agro-ecological zones. The four An. arabiensis were only found in Dassa, a locality in the cotton zone of central Benin. The frequency of distribution of the L1014F allele of the kdr gene varies from 84.48 to 100% in An. gambiae, from 80 to 100% in An. coluzzii and from 0 to 75% in An. arabiensis in the different agro-ecological zones. Moreover, a significant difference is generally observed in the distribution of the L1014F allele (P 

Bassat Q.

Abstract Background Detailed knowledge about viral respiratory disease transmission dynamics within healthcare institutions is essential for effective infection control policy and practice. In the quest to study viral transmission pathways, we aimed to investigate recruitment rates and adherence of healthcare workers (HCWs) and hospital inpatients with a study protocol that involves prospective surveillance based on daily mid-turbinate nasal swabs and illness diaries. Methods Single center prospective surveillance of patients and HCWs in three different hospital departments of a tertiary care center during an entire influenza season in Switzerland. Inpatients and acute care HCWs were asked to provide mid-turbinate nasal swabs and illness diaries on a daily basis. Study protocol adherence and recruitment rates were the primary outcomes of interest. Results A total 251 participants (59 (23.5%) health care workers and 192 (76.5%) inpatients) were recruited from three different hospital wards. Recruitment rates differed between HCWs (62.1% of eligible HCWs) and inpatients (32.5%; P 

Abstract Background Over the past decades there have been outbreaks of mumps in many countries, even in populations that were vaccinated. Some studies suggest that the incidence of mumps is related to meteorological changes, but the results of these studies vary in different regions. To date there is no reported study on correlations between mumps incidence and meteorological parameters in Beijing, China. Methods A time series analysis incorporating selected weather factors and the number of mumps cases from 1990 to 2012 in Beijing was performed. First, correlations between meteorological variables and the number of mumps cases were assessed. A seasonal autoregressive integrated moving average model with explanatory variables (SARIMAX) was then constructed to predict mumps cases. Results Mean temperature, rainfall, relative humidity, vapor pressure, and wind speed were significantly associated with mumps incidence. After constructing the SARIMAX model, mean temperature at lag 0 (β = 0.016, p 

Abstract Background Staphylococcus aureus (S. aureus) is a common cause of bacteremia, which leads to significant morbidity and mortality. We investigated the relationship between time to positivity (TTP) and clinical outcomes in children with S.aureus bacteremia in the China. Methods A retrospective study of Staphylococcus aureus bacteremia inpatient was performed in Children’s Hospital of Chongqing Medical University in China between 29 January 2014 and 29 August 2017. TTP and clinical parameters were determined and analyzed. The receiver operating characteristic (ROC) curves were plotted for optimal cut-off selection, multivariate logistic regression tests were performed to evaluate the association between TTP and clinical outcomes. Results Overall, 84 cases were enrolled. We stated that in-hospital mortality is significantly higher in the early TTP (≤17 h) than in the late TTP (> 17 h) group (57.14% vs 7.14%, P = 0.000). Septic shock occurred in 57.14% of patients with early TTP and in 18.57% of patients with late TTP (P = 0.002). Detailed multivariate and statistical analysis revealed that early TTP, need for vasoactive agent were independent risk factors of in-hospital mortality; early TTP, need for vasoactive agent and APACHE II score ≥ 15 were independent risk factors of septic shock incidence in S. aureus bacteremia children. Conclusions Overall, TTP of ≤17 h appeared to correlate with the worse outcomes for S. aureus bacteremia children. These results have important implications in the assessments and management of pediatric S. aureus bacteremia in a clinical setting. Trial registration Retrospectively registered.…

André B. B. Wilke, Chalmers Vasquez, William Petrie, John C. Beier

by André B. B. Wilke, Chalmers Vasquez, William Petrie, John C. Beier Human mobility in urban environments is a central part of urbanization and has determined the layout of how cities are projected, built and renovated. One of the most problematic issues of urbanization is how to properly dispose of used tires, considering the worldwide annual production of approximately 1.4 billion units every year. Despite the efforts to properly dispose of used tires, they still represent a major problem for public health, notably serving as potential breeding sites for vector mosquitoes. Miami-Dade County, Florida has been suffering from arbovirus outbreaks for decades, including dengue, West Nile and yellow fever viruses. The objective of this study was to survey tire shops inserted in the urban matrix across Miami-Dade County for the presence of vector mosquitoes. This study used a cross-sectional design to survey the production of vector mosquitoes at 12 tires shops. Mosquitoes were found in all but one of the tires shops surveyed. We collected a total of 1,110 mosquitoes comprising 528 adults and 582 immatures. Aedes aegypti and Culex quinquefasciatus were abundantly found in both their immature and adult forms, constituting 99.99% of the mosquito samples collected. Aedes aegypti was the most abundant species recorded displaying the highest values in the Shannon and Simpson indices. The findings of this study demonstrate that vector mosquitoes, primarily Ae. aegypti, are being produced in tires shops in Miami indicating these habitats are highly favorable breeding environments for the production of vector mosquitoes and emphasizing the need to address how the abundance and presence of mosquitoes may vary seasonally in these environments.

Ken’ichi Hagiwara, Yuko Sato, Yoshio Yamakawa, Hideyuki Hara, Minoru Tobiume, Yuko Okemoto-Nakamura, Tetsutaro Sata, Motohiro Horiuchi, Hiroaki Shibata, Fumiko Ono

by Ken’ichi Hagiwara, Yuko Sato, Yoshio Yamakawa, Hideyuki Hara, Minoru Tobiume, Yuko Okemoto-Nakamura, Tetsutaro Sata, Motohiro Horiuchi, Hiroaki Shibata, Fumiko Ono Classical- (C-) and atypical L-type bovine spongiform encephalopathy (BSE) prions cause different pathological phenotypes in cattle brains, and the disease-associated forms of each prion protein (PrPSc) has a dissimilar biochemical signature. Bovine C-BSE prions are the causative agent of variant Creutzfeldt-Jakob disease. To date, human infection with L-BSE prions has not been reported, but they can be transmitted experimentally from cows to cynomolgus monkeys (Macaca fascicularis), a non-human primate model. When transmitted to monkeys, C- and L-BSE prions induce different pathological phenotypes in the brain. However, when isolated from infected brains, the two prion proteins (PrPSc) have similar biochemical signatures (i.e., electrophoretic mobility, glycoforms, and resistance to proteinase K). Such similarities suggest the possibility that L-BSE prions alter their virulence to that of C-BSE prions during propagation in monkeys. To clarify this possibility, we conducted bioassays using inbred mice. C-BSE prions with or without propagation in monkeys were pathogenic to mice, and exhibited comparable incubation periods in secondary passage in mice. By contrast, L-BSE prions, either with or without propagation in monkeys, did not cause the disease in mice, indicating that the pathogenicity of L-BSE prions does not converge towards a C-BSE prion type in this primate model. These results suggest that, although C- and L-BSE prions propagated in cynomolgus monkeys exhibit similar biochemical PrPSc signatures and consist of the monkey amino acid sequence, the two prions maintain strain-specific conformations of PrPSc in which they encipher and retain unique pathogenic traits.

Chew EY.

Diabetic retinopathy is the leading cause of blindness and visual impairment in the working-age population in the United States and worldwide. Diabetic macular edema, a vision-threatening form of diabetic retinopathy, is the swelling or thickening of the retina at the macula, the structure that is responsible for the highest resolution of vision. Diabetic macular edema may occur in any stage of diabetic retinopathy, ranging from minimal diabetic retinopathy to severe proliferative diabetic retinopathy, which is the other form of vision-threatening diabetic retinopathy.

Desai, Rupak; Hanna, Bishoy; Singh, Sandeep; Omar, Ahmed; Deshmukh, Abhishek; Kumar, Gautam; Foreman, Marilyn G.; Sachdeva, Rajesh

Objectives: Atrial fibrillation is frequently seen in sepsis-related hospitalizations. However, large-scale contemporary data from the United States comparing outcomes among sepsis-related hospitalizations with versus without atrial fibrillation are limited. The aim of our study was to assess the frequency of atrial fibrillation and its impact on outcomes of sepsis-related hospitalizations. Design: Retrospective cohort study. Setting: The National Inpatient Sample databases (2010–2014). Patients: Primary discharge diagnosis of sepsis with and without atrial fibrillation were identified using prior validated International Classification of Diseases, 9th Edition, Clinical Modification codes. Interventions: None. Measurements and Main Results: Overall, 5,808,166 hospitalizations with the primary diagnosis of sepsis, of which 19.4% (1,126,433) were associated with atrial fibrillation. The sepsis-atrial fibrillation cohort consisted of older (median [interquartile range] age of 79 yr [70–86 yr] vs 67 yr [53–79 yr]; p < 0.001) white (80.9% vs 68.8%; p < 0.001) male (51.1% vs 47.5%; p < 0.001) patients with an extended length of stay (median [interquartile range] 6 d [4–11 d] vs 5 d [3–9 d]; p < 0.001) and higher hospitalization charges (median [interquartile range] $44,765 [$23,234–$88,657] vs $35,737 [$18,767–$72,220]; p < 0.001) as compared with the nonatrial fibrillation cohort. The all-cause mortality rate in the sepsis-atrial fibrillation cohort was significantly higher (18.4% and 11.9%; p = 0.001) as compared with those without atrial fibrillation. Although all-cause mortality (20.4% vs 16.6%) and length of stay (median [interquartile range] 7 d [4–11 d] vs 6 d [4–10 d]) decreased between 2010 and 2014, hospitalization charges increased (median [interquartile range] $41,783 [$21,430–$84,465] vs $46,251 [$24,157–$89,995]) in the sepsis-atrial fibrillation cohort. The greatest predictors of mortality in the atrial fibrillation-sepsis cohort were African American race, female gender, advanced age, and the presence of medical comorbidities. Conclusions: The presence of atrial fibrillation among sepsis-related hospitalizations is a marker of poor prognosis and increased mortality. Although we observed rising trends in sepsis and sepsis-atrial fibrillation–related hospitalizations during the study period, the rate and odds of mortality progressively decreased. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: rsachdeva@msm.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Meester RS, Mannalithara A, Lansdorp-Vogelaar I, et al.

This cancer epidemiology study uses SEER program data to describe trends in stage of incident colorectal cancer in adults aged 40-49 years between 1975 and 2015 to understand if apparent increases in incidence are due to earlier detection or true increases in risk.

Perak AM, Ning H, Kit BK, et al.

This national survey study uses National Health and Nutrition Examination Survey data from 1999-2016 to characterize trends in levels of lipids and apolipoprotein B in US youths aged 6 to 19 years.

Courtney M. Yuen, Ana K. Millones, Carmen C. Contreras, Leonid Lecca, Mercedes C. Becerra, Salmaan Keshavjee

by Courtney M. Yuen, Ana K. Millones, Carmen C. Contreras, Leonid Lecca, Mercedes C. Becerra, Salmaan Keshavjee Background Appropriate management of people exposed in the home to tuberculosis is essential to prevent morbidity. These household contacts, particularly children, should receive preventive therapy to prevent them from falling ill. However, few people receive preventive therapy worldwide. We sought to determine whether a community-based accompaniment intervention could improve tuberculosis contact management. Methods We conducted a prospective cohort study of household contacts of tuberculosis patients who initiated treatment during September 2015-June 2016 in Lima, Peru. Enrolled households received an intervention comprising home visits, transport vouchers, assistance coordinating evaluation procedures, and adherence support during preventive therapy. To evaluate the impact of the intervention, we conducted retrospective chart reviews of all patients initiating treatment during 6-month baseline and intervention periods. Results We enrolled 314 household contacts of 109 index patients. Of these, 283 (90%) completed evaluation, and 4 (1%) were diagnosed with tuberculosis. Preventive therapy was prescribed for 35/38 (92%) contacts 0–19 years old who were eligible under Peruvian guidelines. Preventive therapy was also prescribed for 6/26 (23%) contacts with unknown eligibility due to lack of a tuberculin skin test (TST), and 20/69 (29%) who were ineligible either because of a negative TST result or exposure to a drug-resistant or extrapulmonary case. Of the 61 contacts who were prescribed preventive therapy, 57 (93%) initiated treatment, and 51 (91%) completed treatment. The proportion of contacts who completed evaluation increased from 42% during the baseline period to 71% during the evaluation period (risk ratio [RR] = 1.73, 95% confidence interval [95% CI]: 1.41–2.13). The proportion of contacts who initiated preventive therapy increased from 15% to 40% (RR = 2.45, 95% CI: 1.42–4.22). Conclusion Accompaniment of TB patient households greatly improved the evaluation of household contacts for TB and increased the use of preventive therapy.…

Abstract Background Tuberculosis (TB) continues to be a public health challenge in Saudi Arabia, particularly for the elderly. This study was conducted to estimate mortality per 1000 person-year among TB and resistant TB cases and to identifying factors associated with mortality. Methods This is a retrospective cohort study of 713 new TB cases at King Abdulaziz Medical City in Riyadh diagnosed between January 1, 2000, and December 31, 2016. Patient medical records and microbiology lab databases were used to identify TB cases. Through reviews were conducted of patients’ medical records, including physician notes, physical examinations, radiology (scans and imaging), laboratory tests, and follow-up notes. Collected data include demographic information, clinical features, diagnoses, comorbidities, and death rates. Results Of the 713 TB patients included in this study, 110 died, giving an average mortality rate of 22 per 1000 person-years (PY; 95% CI: 18.2–26.4). Elderly patients (≥ 60 years) had a higher mortality rate of 36.5 per 1000 PY (95% CI: 28.9–45.5). As age increases by one year, the hazard of mortality increase by 2.4% (aHR: 1.024 [95% CI: 1.009–1.039, P = 0.002]). Higher hazard of mortality was found among males (aHR: 2.014 [95% CI: 1.186–3.418, P = 0.010]). Patients with respiratory and other types of comorbidities and cancer had a higher mortality hazard (aHR: 1.898 [95% CI: 1.005–3.582, P = 0.048]; aHR: 2.346 [95% CI: 1.313–4.192, P = 0.004]; aHR: 3.292 [95% CI: 1.804–6.006, P = 0.001]), respectively. Multidrug-resistant TB (MDR-TB) was found in 2 cases (0.28%) (95% CI: 0.08–1.02), 1.68% were resistant to only one antibiotic, 0.14% had rifampicine-resistant TB (RR-TB), 0.28% had MDR-TB, and 0.14% had extensively drug-resistant TB (XDR-TB). Conclusions The mortality rate among TB patients was found to be 22 per 1000 person-year at our center. TB was associated with high mortality rates among males, the elderly, and patients with cancer, respiratory illness, and other comorbidities. Future clinical practice should include establishing an efficient TB diagnostic program and continued hazard assessment of TB treatment options.…

Sancar F.

The FDA has approved the first 2-drug regimen of dolutegravir and lamivudine for patients with treatment-naive HIV.

Flory J, Lipska K.

This JAMA Insights Clinical Update reviews the clinical use, safety, contraindications, and alternatives to metformin, the first-line treatment for type 2 diabetes.

Friedrich MJ.

Diarrheal diseases resulting from scarce clean water and sanitation in countries with protracted armed conflicts take more children’s lives than the violence itself, according to a recent United Nations Children’s Fund (UNICEF) report.

Temkin E, Carmeli Y, .

AbstractEstimates of the number of deaths from antimicrobial-resistant (AMR) infections are important data for clinicians and public health officials advocating for resources to prevent and treat these infections. The aims of this paper are to describe the various approaches to calculating deaths from AMR infections, to compare the tally of deaths by each approach, and to explain how to interpret the results. Currently, none of the three methods employed by vital statistics systems to count deaths from specific causes (underlying cause of deaths, multiple causes of death, and avoidable deaths) count deaths from AMR infections. These deaths can be estimated by four approaches: case-fatality rate, infection-related mortality, and excess mortality using controls with antibiotic-susceptible infections or controls without antibiotic-resistant infections. When encountering discrepant estimates of AMR-related deaths, it is important to consider which method was used and whether it was the right method to answer the question being asked.