Candida endocarditis: Update on management considerations.

The rise in incidence rates of invasive candidiasis warrants an increase in attention and efforts toward preventing and treating this virulent infection. Cardiac involvement is one of the most feared sequelae and has a poor prognosis. Despite the introduction of several novel antifungal agents over the past quarter century, complications and mortality rates due to Candida endocarditis have remained high. Although fungal endocarditis has a mechanism similar to bacterial endocarditis, no specific diagnostic criteria or algorithm exists to help guide its management. Furthermore, recent data has questioned the current guidelines recommending a combined approach of antifungal agents with surgical valve or indwelling prostheses removal. With the emergence of multidrug-resistant Candida auris, a focus on improved prophylactic measures and management strategies is necessary.

Synergistic effects of dual antimicrobial combinations of synthesized N-heterocycles or MgO nanoparticles with nisin against the growth of Aspergillus fumigatus: In vitro study.

Introduction of new inhibitory agents such as peptides, heterocyclic derivatives and nanoparticles (NPs) along with preventive proceedings are effective ways to deal with standard and drug-resistant strains of microorganisms. In this regard, inhibitory activities of some recently synthesized 4-thiazolylpyrazoles, imidazolidine- and tetrahydropyrimidine-2-thiones and magnesium oxide (MgO) NPs alone and in combination with nisin have been assessed against Aspergillus fumigatus. Antimicrobial susceptibility tests were done via broth microdilution, disk diffusion and streak plate methods according to the modified Clinical and Laboratory Standards Institute (CLSI) guidelines. Synergistic effects were also determined as fractional inhibitory concentration (FIC) and fractional fungicidal concentration (FFC) values. Inhibitory potentials of all heterocycles and NPs against A. fumigatus were proved based on inhibition zone diameter (IZD) values in the range of 7.72 - 16.85 mm, minimum inhibitory concentration (MIC) values in the range of 64.00 - 512 µg mL-1 and minimum fungicidal concentration (MFC) values in the range of 256 - 2048 µg mL-1. Tetrahydropyrimidine derivative 3f showed the best inhibitory properties. Inhibitory activity was not significant with nisin. While antifungal effects of major derivatives were improved by combination with it. The results indicated that the combined treatment of heterocycles used in the present study with nisin might be efficient for mold prevention and removal in foodstuffs or other products.

Symptoms prior to sudden death.

BACKGROUND: Sudden death accounts for up to 15% of all deaths among working age adults. A better understanding of victims' medical care and symptoms reported at their last medical encounter may identify opportunities for interventions to prevent sudden deaths. METHODS: From 2013-15, all out-of-hospital deaths, ages 18-64 reported by Emergency Medical Services (EMS) in Wake County, North Carolina were screened and adjudicated to identify 399 victims of sudden death, 264 of whom had available medical records. Demographic and clinical characteristics and prescribed medications were compared between victims with versus without a medical encounter within one month preceding death with chi-square tests and t-tests, as appropriate. Symptoms reported in medical encounters within one month preceding death were analyzed. RESULTS: Among the 264 victims with available medical records, 73 (27.7%) had at least one encounter within a month preceding death. These victims were older and more likely to have multiple chronic illnesses, yet most were not prescribed evidence-based medicines. Of these 73 victims, 30 (41.1%) reported cardiac symptoms including dyspnea, edema, and chest pain. CONCLUSIONS: Many victims seek medical care and report cardiac symptoms in the month prior to sudden death. However, medications that might prevent sudden death are under prescribed. These findings suggest that there are opportunities for intervention to prevent sudden death.

Missed Opportunities for Prevention of Sudden Death.

BACKGROUND: We assessed patterns of health care utilization to further characterize chronic comorbidities prior to sudden death. METHOD: From March 1, 2013, through February 28, 2015, all out-of-hospital deaths aged 18-64 reported by emergency medical services in Wake County, North Carolina, were screened to adjudicate 399 sudden death victims. Retrospective analysis of clinical records on victims determined health care utilization. Health care utilization frequency was assessed by latent growth curve analysis. RESULTS: Medical records were available for 264 victims (aged 53.5 ± 9.2) who were predominantly male (65%) and white (64%). Of these, 210 (80%) victims had at least one visit within two years of death and 73 (28%) had a visit within one month of death. Over the two years prior to death, there was an increasing frequency of doctor visits (P < .001). Victims averaged 3.7 ± 4.6 yearly visits and were categorized into low (0.4 visits/year), medium (3.3 visits/year), and high (11.4 visits/year) tiers of visit frequency. The high visit tier had a greater prevalence of coronary artery disease (38%), hypertension (80%), diabetes (58%), depression (74%), anxiety (64%), and substance misuse (46%) (P < .001). LIMITATIONS: Those who were non-free-living, minors, without formal medical records, and adults aged 65 and older were excluded from the analysis. CONCLUSIONS: A majority of sudden death victims utilized health care within two years prior to death and had comorbidities that may have contributed to their unexpected death. The increasing frequency of visits prior to death provided an opportunity for health care providers to address potential victims' chronic medical conditions to potentially prevent death.

High Prevalence of Diabetes Mellitus and Mental Illness Among Victims of Sudden Death.

OBJECTIVES: Diabetes mellitus (DM) increases the risk of cardiovascular disease and is associated with sudden death. Mental illness among individuals with DM may confound medical care. This study assessed the association of mental illness with DM and poorly controlled DM in sudden death victims. METHODS: We screened out-of-hospital deaths ages 18 to 64 years in Wake County, North Carolina from 2013 to 2015 to adjudicate sudden deaths. We abstracted demographics and clinical characteristics from health records. Mental illness included anxiety, schizophrenia, bipolar disorder, or depression. Poorly controlled DM was defined as a hemoglobin A1c >8 or taking ≥3 medications for glycemic control. Logistic regression assessed the association between DM and mental illness. RESULTS: Among victims with available records, 109 (29.4%) had DM. Of those, 62 (56.9%) had mental illness. Mental illness was present in 53.42% and 63.89% of victims with mild and poorly controlled DM, respectively. Mental illness was associated with DM (adjusted odds ratio 2.46, 95% confidence interval 1.57-3.91). Victims with poorly controlled DM were more likely to have mental illness (adjusted odds ratio 2.66, 95% confidence interval 1.14-6.18). CONCLUSIONS: DM is a common comorbid condition in sudden death victims. Among victims, mental illness is associated with the control of DM. Early management of comorbid mental illnesses may improve the care of patients with DM and reduce the incidence of sudden death.

Changes in the prevalence of measures associated with hypertension among Iranian adults according to classification by ACC/AHA guideline 2017.

BACKGROUND: Different definitions have been proposed to categorize hypertension. We aimed to investigate the difference in prevalence of measures associated with hypertension according to the American College of Cardiology/American Heart Association (ACC/AHA) criteria versus Joint National Committee 7 (JNC7) criteria. METHODS: We analyzed the data of 10,000 participants of Yazd Health Study (YaHS) aged 20-69 years. Blood pressure was measured three times with standard protocol defined by ACC/AHA. Prevalence of high blood pressure measure was compared in both definitions and absolute differences reported. RESULTS: The prevalence of high blood pressure in our measurement was 61.0% according to ACC/AHA, and 28.9% according to JNC 7. The prevalence of self-reported hypertension was 18.6%. Age and sex standardized prevalence rates of high blood pressure measure indicates a 2.4-fold increase in the prevalence rate (30.1% absolute difference) by the ACC/AHA guideline. While the prevalence increased in all age groups, the age group of 20-29 showed the highest relative increase by 3.6 times (10.6% vs. 38.1%). High blood pressure measure among people with diabetes increased from 45.8 to 75.3% with the ACC/AHA guideline. Of the people who had no past history of diagnosed hypertension (n = 7887), 55.1 and 22.7% had high blood pressure measure by ACC/AHA and JNC-7 guidelines, respectively. From JNC7 to ACC/AHA, the overall difference in unawareness about HTN increased by 32.4%. CONCLUSION: Prevalence of hypertension associated measures increased over two folds by using the ACC/AHA criteria compared to JNC 7. Also, change in the criteria, reduces awareness of the disease and increases uncontrolled hypertension respectively. More research is needed to determine if the new definitions can affect management of hypertension in societies. Considering local priorities and implication of cost effective may improve implementation of new definitions for hypertension in different countries.

Coronary Artery Disease and Atherosclerotic Risk Factors in a Population-Based Study of Sudden Death.

BACKGROUND: Sudden death is a public health problem with major impact on society. Coronary artery disease (CAD) is believed to underlie 60-80% of these deaths. While deaths from CAD have decreased in the recent decades, sudden death rates remain unacceptably high. OBJECTIVE: We aimed to assess the prevalence of CAD and its risk factors among 18-64-year-old adults in a population-based case registry of sudden deaths and compare them to a living population from the same geographical area. DESIGN: From 2013 to 2015, all sudden deaths among 18-64-year-old adults in Wake County, NC, were identified (n = 371). A comparison group was formed by randomly selecting individuals from an electronic health record repository of a major healthcare system in the area (N = 4218). MAIN MEASURES: Prevalence of CAD and its risk factors among cases of sudden death and living population across sex and age groups. Odds of sudden death associated with atherosclerotic risk factors and comorbidities. KEY RESULTS: CAD was present in 14.8% of sudden death cases. Among sudden death victims, most risk factors and comorbidities were more common in the older age group, except for obesity which was more common in younger cases, and diabetes which was equally prevalent in younger and older cases. Compared to living population, sudden death cases had higher prevalence of atherosclerotic risk factors across all gender and age groups. Sudden death cases had a numerically higher number of risk factors compared to living population, regardless of age group or presence of CAD. CONCLUSIONS: Coronary artery disease is not common among sudden death cases, but risk factors and comorbidities are prevalent. Our findings support the changing etiology of sudden death. In the absence of clinically diagnosed CAD, use of novel imaging modalities and biomarkers may identify high-risk individuals and lead to prevention of sudden death.

Years of Life and Productivity Loss Because of Adult Sudden Unexpected Death in the United States.

BACKGROUND: Few studies have evaluated the years of life lost (YLL) and productivity loss due to sudden unexpected death (SUD). The burden of SUD on society is undetermined because of lack of population-based studies and comprehensive adjudication methods. OBJECTIVE: We estimated YLL and productivity loss from SUD in working-age adults and compared it with the leading causes of death in the United States. METHODS: We screened all out of hospital deaths among people aged 20-64 in Wake County, NC from 2013 to 2015 to adjudicate SUDs. We extrapolated Wake County incidence to estimate the age-standardized and sex-standardized rate of SUD in the United States. YLL was calculated based on the remaining life expectancy of the victims. Incorporating market and housekeeping value estimated the present value of lifetime productivity loss because of SUD. RESULTS: SUD incidence rates in the US adults aged 20-64 were 49.3 (95% confidence interval, 41.2-58.3) and 21.7 (95% confidence interval, 16.5-27.8) per 100,000 among men and women, respectively. SUD resulted in the loss of 2 million years of life, accounting for 10.0% of YLL from all causes of death. Among natural causes of death, YLL from SUD was only lower than that from all cancers combined and heart disease. Lifetime productivity loss because of SUD was ~$51 billion, exceeding productivity loss from any individual cancer. CONCLUSION: SUD is an important source of YLL and productivity loss among adults aged 20-64. Such a high burden on society justifies prioritizing health policies and interventions toward preventing SUD.

Three -Agent Preemptive Analgesia, Pregabalin-Acetaminophen-Naproxen, in Laparotomy for Cancer: A Randomized Clinical Trial.

BACKGROUND: Pain management after abdominal surgery is a critical issue in cancer patients undergoing laparotomy. Opioid analgesics commonly used postoperatively have significant side effects and can postpone restoring normal life. Administration of analgesics before the surgery by inhibiting pain cascades may be an effective method for more efficient pain control. OBJECTIVES: This study aimed to investigate the effect of the preemptive use of oral pregabalin-acetaminophen-naproxen on pain control and morphine consumptions in cancer patients undergoing laparotomy. PATIENTS AND METHODS: A total of 40 cancer patients scheduled for open abdominal surgery were randomized into the two groups. one group received combination of pregabalin 150 mg, acetaminophen 1 g and naproxen 250 mg (the PAN group) an hour before laparotomy. Following the surgery, morphine was administered on a protocolized schedule based on patients' demand for pain control. Postoperative pain level was assessed using universal pain assessment tool (UPAT) at 0, 2, 4, 6, 12, 24 and 48 hours after the operation. The postoperative morphine dose and complications were noted. Data were analyzed using SPSS version 16. RESULTS: Patients in the PAN group had significantly lower UPAT scores at 0, 2, 4, 6, 12, 24 and 48 hours after the surgery than those in the control group (P = 0.008, 0.021, 0.008, 0.047, 0.004, 0.001, and 0.001). The mean dose of postoperative morphine consumption in the PAN group was 37% less than the control group (P = 0.001). The complications were not significantly different between the two groups. CONCLUSIONS: Preemptive use of pregabalin-acetaminophen-naproxen decreases intensity of pain and morphine consumption in the cancer patients after laparotomy without significant complications.

Patients' Characteristics, Histopathological Findings, and Tumor Stage in Different Types of Malignant Melanoma: A Retrospective Multicenter Study.

Cutaneous malignant melanoma (CMM) is currently the most fatal of skin cancers accounting for 50000 deaths annually. Five distinct melanomas are described histopathologically: superficial spreading, lentigo maligna, nodular, acral lentiginous and mucosal melanoma. The aim of this study was to investigate the characteristics of patients with various types of malignant melanoma and evaluate histopathological findings. In this retrospective study, we obtained our data from the records of 111 patients with melanoma. Biopsied specimens were collected and re-evaluated. Demographic information and histopathological findings were noted. SPSS 16 was used for analyzing data. Chi-square and one-way ANOVA was conducted for comparing categorical and numerical variables respectively. The mean age of patients was 59.33±14.68 years old. Most common melanoma type was acral lentiginous (40.5%), followed by nodular (35.1%) and mucosal (10.8%). The highest tumor thickness was viewed in nodular melanoma followed by mucosal melanoma. The highest rate of metastasis, microsatellitosis, perineural invasion and Clark level of the invasion were reported in nodular and acral lentiginous respectively. The most frequent rate of ulceration and vascular invasion was reported in mucosal melanoma. Distribution of melanoma types varies largely in different regions. Lack of classic presentations in some types necessitate specific public education about warning signs. Histopathological and pathological characteristics in melanoma can aid in better staging and management of the tumor.

Mortality Rate and Years of Life Lost Due to Prostate Cancer in Yazd Province, Iran: A 10-year study.

OBJECTIVES: Prostate cancer is a leading cause of cancer-related deaths. The number of deaths and years of life lost (YLL) due to a disease can be used to monitor health status, assess healthcare needs and determine the prioritisation and allocation of health resources within a population; in addition, the latter calculation can serve as a baseline indicator of premature mortality. This study aimed to measure prostate cancer-related mortality and YLL in Yazd Province, Iran. METHODS: This study included all prostate cancer-related deaths in Yazd Province reported between March 2001 and March 2010. Mortality data were obtained from a provincial death registration system which integrates data from different sources. YLL was calculated based on an individual's age at death and their life expectancy according to age group. RESULTS: During the study period, prostate cancer was the fourth most common fatal cancer among men, resulting in 324 deaths or 10.0% of all cancer-related deaths. The crude mortality rate per 100,000 individuals increased from 4.7 in 2001 to 8.8 in 2010. Premature deaths caused 1,358.7 YLL and the YLL caused by prostate cancer deaths more than doubled from 94.7 in 2001 to 196.5 in 2010. CONCLUSION: Due to changes in population structure, it is likely that the burden of prostate cancer will continue to increase in Yazd Province. As such, it is necessary that the national health system implements screening programmes and improves public awareness of prostate cancer-associated risk factors.

Multi-Modal Preemptive Analgesia With Pregabalin, Acetaminophen, Naproxen, and Dextromethorphan in Radical Neck Dissection Surgery: A Randomized Clinical Trial.

BACKGROUND: Preemptive analgesia may be considered as a method not only to alleviate postoperative pain but also to decrease analgesic consumption. Different regimens are suggested, but there is currently no standard. OBJECTIVES: The aim was to measure the efficacy of preemptive analgesia with pregabalin, acetaminophen, naproxen, and dextromethorphan in radical neck dissection surgery for reducing the intensity of pain and morphine consumption. PATIENTS AND METHODS: This study was conducted as a randomized double-blind clinical trial. Eighty adult patients (18 to 60 years of age) under the American society of anesthesiologists (ASA) physical status I and II undergoing elective radical neck dissection were enrolled. Patients were randomized into two groups of 40 with a simple randomization method. The case group received a combination of 15 mg/kg acetaminophen, 2.5 mg/kg pregabalin, 7 mg/kg naproxen, and 0.3 mg/kg dextromethorphan administered orally one hour prior to surgery. Postoperative pain was assessed with the universal pain assessment tool (UPAT) at 0, 2, 4, 6, 12, and 24 hours after surgery. Subjects received morphine based on postoperative pain control protocol. Total administered morphine doses were noted. RESULTS: Postoperative pain rates at 0, 2, 4, 6, 12, and 24 hours after surgery were significantly lower for the case group than the control group (P values = 0.014, 0.003, 0.00, 0.00, and 0.00, respectively). Total morphine doses for the preemptive analgesia group were 45% lower than those of the other group. Side effects were similar for both groups. CONCLUSIONS: A single preoperative oral dose of pregabalin, acetaminophen, dextromethorphan, and naproxen one hour before surgery is an effective method for reducing postoperative pain and morphine consumption in patients undergoing radical neck dissection.

Trends in Road Traffic Deaths in Yazd, Iran, 2004 - 2010.

BACKGROUND: Road traffic deaths are a considerable public health problem and a major source of lost financial and human resources. Most mortality occurs in low- and middle-income countries. OBJECTIVES: This study aimed to measure road traffic fatality rates and years of lost life, and also to depict a view of trends in road traffic deaths from 2004 to 2010 in Yazd city, a province in central Iran. MATERIALS AND METHODS: This retrospective case study analyzed road traffic deaths that were classified under the V01 - V99 codes of the ICD-10 in Yazd province from March 2004 to March 2010, using data that were collected from the death registration system of the Yazd province health center. Cases were classified according to age, sex, time of year, and residence (urban vs. rural). Years of lost life and road fatality rate per 100,000 people were calculated. Data were analyzed using chi-square test and ANOVA with SPSS 16. RESULTS: During the seven-year period of this study, 3,028 people in Yazd province died due to road traffic accidents (9.1% of total deaths in the province). Most deaths occurred among people aged 20-24 (15%), men (82.7%), and urban residents (82.6%). Total years of lost life (YLL) were 73,875 (60,337 and 13,489 in men and women, respectively). The road traffic fatality rate per 100,000 was 47.6 in 2004 and 37.6 in 2010. In the study period, the rate of traffic fatalities decreased for men (from 77.9 to 68.5) but this is not the case for women (from 14.8 to 19.2). Road traffic deaths peaked every summer. CONCLUSIONS: Despite the overall reduction trend, the road traffic fatality rate in Yazd province is still alarmingly high compared to national and global data. In addition, the female population shows increasing death rates. These findings can serve as a basis for health care professionals and policymakers to conduct preventive measures, especially during summer, and plan specifically for reducing fatalities in the female population.

Expected Years of Life Lost Due to Adult Cancer Mortality in Yazd ( 2004-2010 ).

The number of deaths is often measured to monitor the population health status and priority of health problems. However, number of years of life lost (YLL) is a more appropriate indicator in some cases. We have calculated the YLL of adult cancers and its trend over the past few years in Yazd to provide planners with baseline data. Data obtained from death registration system were used to calculate the YLL, based on each individual's age at death, and the standardized expected YLL method was applied with a discount rate of 0.03, an age weight of 0.04, and a correction factor of 0.165. All data were analyzed and prepared in Epi6 and Excel 2007. A total of 3,850 death records were analyzed. Some 550 patients in Yazd province aged ≥20 die annually due to cancer (male: female ratio 1.3). The average ages at death in lung, CNS, breast cancer and leukemia cases were 68.5, 59, 58.7 and 61, respectively. The age group of 40-59 with 21 % had the highest cancer mortality percentage. Premature cancer deaths have caused 40,753 YLL (5,823 YLL annually). Females lose on average more life years to cancer than do men (11.6 vs 9.8 years). Lung cancer (12.1%), CNS tumors (11.7%) and leukemia (11.4 %) were the leading causes terms of YLL due to all cancers in both sexes. From 2004 to 2010, cancer-caused YLL as a fraction of all YLL increased from 12.8 to 15.2 %. This study can help in the assessment of health care needs and prioritization. Cancer is the major cause of deaths and the trend is increasing. The use of YLLs is a better index for measurement of premature mortality for ranking of diseases than is death counts. Longer periods of observation will make these trends more robust and will help to evaluate and develop, better public health interventions.

INSTRUMENTS OF HIGH RISK SEXUAL BEHAVIOR ASSESSMENT: A SYSTEMATIC REVIEW.

BACKGROUND: Sexual behavior is a complex activity affecting all aspects of human's life. Risky sexual behaviors impose negative outcomes on family, relationships and health. Unsafe sex is the second most leading cause of disability adjusted life years worldwide. Valid and reliable tools for assessment of risky sexual behaviors are necessary for implementing preventive measures. METHODS: we searched Medline and the Cochrane Library of Systematic Reviews, with the keywords of "risky sexual behavior assessment", "sexual risk assessment", "high risk sexual behavior", "sexual risk taking". By reviewing references of the articles, some complementary studies were added. RESULTS: Assessment can be performed by questionnaire or non-questionnaire instruments. Questionnaires vary depending on their target population, evaluation of risky sexual behavior as a whole or focusing on an associated risk factor. In order to avoid usual biases in self reports, objective biomarker assessment of unprotected sex are employed. These markers include prostate specific antigen, chromosome Y DNA and Seminogelin. CONCLUSION: Risky sexual behavior can be assessed by various subjective and objective methods. While self-reports are more feasible, objective methods offer a higher degree of reliability. Further studies for finding more feasible methods of using biomarkers are recommended.