Assessing the Impact of ED Triage Directives on Febrile Oncology Patient Wait Times.

INTRODUCTION: Fever during chemotherapy is a common and potentially severe complication being increasingly evaluated in emergency departments to minimize morbidity and mortality. Streamlining triage of these patients may improve health outcomes and wait times in the health care system. METHODS: A retrospective chart review of febrile patients undergoing chemotherapy was conducted at a local emergency department to assess the impact of nurse-initiated protocols on wait times. RESULTS: We identified 315 patients undergoing current chemotherapy presenting with fever. Of these, 140 (44%) and 87 (28%) were initiated on the sepsis and febrile neutropenia nurse-initiated protocols, respectively. In total, 197 (63%) were admitted. The febrile neutropenia protocol had a shorter wait time from triage to disposition than the sepsis protocol (403 minutes [SD = 23] vs 329 minutes [SD = 19], t = 1.71, P = 0.01). Furthermore, the febrile neutropenia protocol demonstrated shorter times from both triage to lab results reported, in addition to the physician initial assessment in the admitted patient subgroup. DISCUSSION: Decreased wait times from triage associated with the use of a febrile neutropenia protocol could be accounted for by a lower number of lab results required through this protocol in addition to shorter physician assessment times in the admitted population. This study shows that nurse-initiated protocols may influence door-to-antibiotic time for patients undergoing chemotherapy. By having a targeted protocol for the cancer population, health care centers may be able to demonstrate decreased health care expenditure and increased resource availability. Furthermore, as the current population of patients undergoing chemotherapy is at a high risk for neutropenia, prompt management is crucial to minimize mortality.

Particulate Air Pollution from Wildfires in the Western US under Climate Change.

Wildfire can impose a direct impact on human health under climate change. While the potential impacts of climate change on wildfires and resulting air pollution have been studied, it is not known who will be most affected by the growing threat of wildfires. Identifying communities that will be most affected will inform development of fire management strategies and disaster preparedness programs. We estimate levels of fine particulate matter (PM2.5) directly attributable to wildfires in 561 western US counties during fire seasons for the present-day (2004-2009) and future (2046-2051), using a fire prediction model and GEOS-Chem, a 3-D global chemical transport model. Future estimates are obtained under a scenario of moderately increasing greenhouse gases by mid-century. We create a new term "Smoke Wave," defined as ≥2 consecutive days with high wildfire-specific PM2.5, to describe episodes of high air pollution from wildfires. We develop an interactive map to demonstrate the counties likely to suffer from future high wildfire pollution events. For 2004-2009, on days exceeding regulatory PM2.5 standards, wildfires contributed an average of 71.3% of total PM2.5. Under future climate change, we estimate that more than 82 million individuals will experience a 57% and 31% increase in the frequency and intensity, respectively, of Smoke Waves. Northern California, Western Oregon and the Great Plains are likely to suffer the highest exposure to widlfire smoke in the future. Results point to the potential health impacts of increasing wildfire activity on large numbers of people in a warming climate and the need to establish or modify US wildfire management and evacuation programs in high-risk regions. The study also adds to the growing literature arguing that extreme events in a changing climate could have significant consequences for human health.

Strategies to reduce mortality and morbidity due to AIDS-related cryptococcal meningitis in Latin America

Latin America is the region with the third most AIDS-related cryptococcal meningitis infections globally. Highly active antiretroviral therapy (HAART) has reduced the number of infections; however, the number of deaths and the case-fatality rate continues to be unacceptable. In this review, we focus on the burden of AIDS-related cryptococcosis in Latin America and discuss potential strategies to reduce early mortality from Cryptococcus. In this review, we highlight the importance of: (1) earlier HIV diagnosis and HAART initiation with retention-in-care to avoid AIDS; (2) pre-HAART cryptococcal antigen (CRAG) screening with preemptive fluconazole treatment; (3) better diagnostics (e.g. CRAG testing); and (4) optimal treatment with aggressive management of intracranial pressure and induction therapy with antifungal combination. Implementation of these strategies can reduce cryptococcal-related deaths, improve care, and reduce healthcare costs.

Strategies to reduce mortality and morbidity due to AIDS-related cryptococcal meningitis in Latin America.

Latin America is the region with the third most AIDS-related cryptococcal meningitis infections globally. Highly active antiretroviral therapy (HAART) has reduced the number of infections; however, the number of deaths and the case-fatality rate continues to be unacceptable. In this review, we focus on the burden of AIDS-related cryptococcosis in Latin America and discuss potential strategies to reduce early mortality from Cryptococcus. In this review, we highlight the importance of: (1) earlier HIV diagnosis and HAART initiation with retention-in-care to avoid AIDS; (2) pre-HAART cryptococcal antigen (CRAG) screening with preemptive fluconazole treatment; (3) better diagnostics (e.g. CRAG testing); and (4) optimal treatment with aggressive management of intracranial pressure and induction therapy with antifungal combination. Implementation of these strategies can reduce cryptococcal-related deaths, improve care, and reduce healthcare costs.

Role of quantitative CSF microscopy to predict culture status and outcome in HIV-associated cryptococcal meningitis in a Brazilian cohort.

This retrospective study aimed to evaluate the clinical, laboratory, and quantitative cerebrospinal fluid (CSF) cryptococcal cell counts for associations with in-hospital outcomes of HIV-infected patients with cryptococcal meningitis. Ninety-eight HIV-infected adult patients with CSF culture-proven cryptococcal meningitis were admitted between January 2006 and June 2008 at a referral center in Sao Paulo, Brazil. Cryptococcal meningitis was the first AIDS-defining illness in 69%, of whom 97% (95/98) had known prior HIV infection. The median CD4+ T-cell count was 39 cells/µL (interquartile range 17-87 cells/µL). Prior antiretroviral therapy was reported in 50%. Failure to sterilize the CSF by 7-14 days was associated with baseline fungal burden of ≥ 10 yeasts/µL by quantitative CSF microscopy (odds ratio [OR] = 15.3, 95% confidence interval [CI] 4.1-56.7; P < 0.001) and positive blood cultures (OR = 11.5, 95% CI 1.2-109; P = 0.034). At 7-14 days, ≥ 10 yeasts/µL CSF was associated with positive CSF cultures in 98% versus 36% with <10 yeasts/µL CSF (P < 0.001). In-hospital mortality was 30% and was associated with symptoms duration for >14 days, altered mental status (P < 0.001), CSF white blood cell counts <5 cells/µL (P = 0.027), intracranial hypertension (P = 0.011), viral loads >50,000 copies/mL (P = 0.036), ≥ 10 yeasts/µL CSF at 7-14 days (P = 0.038), and intracranial pressure >50 cmH(2)0 at 7-14 days (P = 0.007). In conclusion, most patients were aware of their HIV status. Fungal burden of ≥ 10 yeasts/µL by quantitative CSF microscopy predicted current CSF culture status and may be useful to customize the induction therapy. High uncontrolled intracranial pressure was associated with mortality.

Repellency Effects of Essential Oils of Myrtle (Myrtus communis), Marigold (Calendula officinalis) Compared with DEET against Anopheles stephensi on Human Volunteers.

BACKGROUND: Malaria and leishmaniasis are two most significant parasitic diseases which are endemic in Iran. Over the past decades, interest in botanical repellents has increased as a result of safety to human. The comparative efficacy of essential oils of two native plants, myrtle (Myrtus communis) and marigold (Calendula officinalis) collected from natural habitats at southern Iran was compared with DEET as synthetic repellent against Anopheles stephensi on human subjects under laboratory condition. METHODS: Essential oils from two species of native plants were obtained by Clevenger-type water distillation. The protection time of DEET, marigold and myrtle was assessed on human subject using screened cage method against An. stephensi. The effective dose of 50% essential oils of two latter species and DEET were determined by modified ASTM method. ED(50) and ED(90) values and related statistical parameters were calculated by probit analysis. RESULTS: The protection time of 50% essential oils of marigold and myrtle were respectively 2.15 and 4.36 hours compared to 6.23 hours for DEET 25%. The median effective dose (ED(50)) of 50% essential oils was 0.1105 and 0.6034 mg/cm(2) respectively in myrtle and marigold. The figure for DEET was 0.0023 mg/cm(2). CONCLUSION: This study exhibited that the repellency of both botanical repellents was generally lower than DEET as a synthetic repellent. However the 50% essential oil of myrtle showed a moderate repellency effects compared to marigold against An. stephensi.

Larvicidal Activity of Essential Oils of Apiaceae Plants against Malaria Vector, Anopheles stephensi.

BACKGROUND: Plant extracts and oils may act as alternatives to conventional pesticides for malaria vector control. The aim of this study was to evaluate the larvicidal activity of essential oils of three plants of Apiaceae family against Anopheles stephensi, the main malaria vector in Iran. METHODS: Essential oils from Heracleum persicum, Foeniculum vulgare and Coriandrum sativum seeds were hydro distillated, then their larvicidal activity were evaluated against laboratory-reared larvae of An. stephensi according to standard method of WHO. After susceptibility test, results were analysis using Probit program. RESULTS: Essential oils were separated from H. persicum, F. vulgare and C. sativum plants and their larvicidal activities were tested. Result of this study showed that F. vulgare oil was the most effective against An. stephensi with LC(50) and LC(90) values of 20.10 and 44.51 ppm, respectively. CONCLUSION: All three plants essential oil can serve as a natural larvicide against An. stephensi. F. vulgare oil exhibited more larvicidal properties.

Ring enhancing intracranial lesion responding to antituberculous treatment in an HIV-infected patient.

Cerebral tuberculomas constitute a major differential diagnosis of cerebral toxoplasmosis in human immunodeficiency virus (HIV)-infected patients in developing countries. We report the case of a 34-year old woman co-infected with HIV and possible disseminated tuberculosis (hepatitis, lymphadenopathy, and pleural effusion) who presented a large and solitary intracranial mass lesion. Despite extensive diagnostic efforts, including brain, ganglionar, and liver biopsies, no definitive diagnosis was reached. However, a trial with first-line antituberculous drugs led to a significant clinical and radiological improvement. Atypical presentations of cerebral tuberculomas should always be considered in the differential diagnosis of intracranial mass lesions in HIV-infected patients and a trial with antituberculous drugs is a valuable strategy to infer the diagnosis in a subset of patients.

Ring enhancing intracranial lesion responding to antituberculous treatment in an HIV-infected patient / Lesão intracraniana que respondeu ao tratamento anti-tuberculoso em paciente infectado pelo HIV

Cerebral tuberculomas constitute a major differential diagnosis of cerebral toxoplasmosis in human immunodeficiency virus (HIV)-infected patients in developing countries. We report the case of a 34-year old woman co-infected with HIV and possible disseminated tuberculosis (hepatitis, lymphadenopathy, and pleural effusion) who presented a large and solitary intracranial mass lesion. Despite extensive diagnostic efforts, including brain, ganglionar, and liver biopsies, no definitive diagnosis was reached. However, a trial with first-line antituberculous drugs led to a significant clinical and radiological improvement. Atypical presentations of cerebral tuberculomas should always be considered in the differential diagnosis of intracranial mass lesions in HIV-infected patients and a trial with antituberculous drugs is a valuable strategy to infer the diagnosis in a subset of patients.

Os tuberculomas cerebrais constituem diagnóstico diferencial importante da toxoplasmose cerebral em pacientes infectados pelo vírus da imunodeficiência humana (HIV) de países em desenvolvimento. Os autores relatam o caso de uma mulher HIV positiva de 34 anos de idade, que apresentou provável tuberculose disseminada (hepatite, adenomegalia, e derrame pleural) associada à lesão expansiva cerebral única e gigante. Apesar dos esforços diagnósticos realizados, incluindo biópsia cerebral, ganglionar e hepática, o diagnóstico etiológico não foi confirmado. Porém, a resposta clínico-radiológica ao tratamento tuberculostático permitiu definir o diagnóstico de tuberculoma cerebral e a paciente teve alta hospitalar. Apresentações atípicas de tuberculomas cerebrais devem ser sempre consideradas no diagnóstico diferencial das lesões expansivas cerebrais em pacientes infectados pelo HIV e o uso do tratamento tuberculostático constitui ferramenta útil na definição diagnóstica em um sub-grupo de pacientes.

Effect of washing on the bioefficacy of insecticide-treated nets (ITNs) and long-lasting insecticidal nets (LLINs) against main malaria vector Anopheles stephensi by three bioassay methods.

BACKGROUND & OBJECTIVES: The use of pyrethoid impregnated bednets is one of the main malaria vector control strategies worldwide. The objective of the present study was to evaluate the bioefficacy of bednets impregnated with various pyrethroids after repeated washings. METHODS: The effectiveness of bednets impregnated with permethrin, deltamethrin, bifenthrin, etofenprox and long-lasting bednets like OlysetNet and PermaNet which were provided by WHOPES was evaluated. The tests were carried out according to the WHO-recommended methods. Malaria vector, Anopheles stephensi was exposed to impregnated bednets for 3 min and the mortality was measured after 24 h recovery period. Knockdown was measured as well. RESULTS: Results of three methods of bioassay tests showed that between two LLINs, PermaNet was more efficient than OlysetNet. Results of ITNs exhibited that deltamethrin and permethrin were more effective than etofenprox and bifenthrin as impregnants. INTERPRETATION & CONCLUSION: Findings of this study will be useful for WHO, local authorities and people who wish to use different pyrethroid-impregnated bednets for malaria vector control.

Comparative performance of imagicides on Anopheles stephensi, main malaria vector in a malarious area, southern Iran.

BACKGROUND & OBJECTIVES: Jiroft district has subtropical climate and prone to seasonal malaria transmission with annual parasite index (API) 4.2 per 1000 in 2006. Anopheles stephensi Liston is a dominant malaria vector. The monitoring of insecticide susceptibility and irritability was conducted using discriminative dose as described by WHO. METHODS: The IV instar larvae were collected from different larval breeding places and transported to the temporary insectary, fed with Bemax and then 2-3 days-old emerged and sugar-fed adults were used for susceptibility and irritability tests employing WHO methods and kits to organochlorine (OC) and pyrethroid (PY) insecticides. RESULTS: Mortality rates of field strain of An. stephensi were 91.3 +/- 0.14 and 90 +/- 0.47% to DDT and dieldrin, respectively at one hour exposure time but was susceptible to all pyrethroids tested. The average number of take-offs per min per adult was 2.09 +/- 0.13 for DDT, 0.581 +/- 0.05 for dieldrin, 1.85 +/- 0.08 for permethrin, 1.87 +/- 0.21 for lambda-cyhalothrin, 1.53 +/- 0.13 for cyfluthrin, and 1.23 +/- 0.1 for deltamethrin. INTERPRETATION & CONCLUSION: Currently, deltamethrin is being used for indoor residual spraying against malaria vectors in the endemic areas of Iran. The findings revealed that the main malaria species is susceptible to all pyrethroids including deltamethrin, permethrin, cyfluthrin and lambda-cyhalothrin but was tolerant to DDT and dieldrin. This report and the finding are coincided with results of previous studies carried out during 1957-61 in the same area. Irritability tests to OC and PY insecticides revealed the moderate level of irritability to DDT compared to pyrethroids and dieldrin. Monitoring for possible cross-resistance between OC and PY insecticides should come into consideration for malaria control programme.

BK virus associated meningoencephalitis in an AIDS patient treated with HAART.

A severely immune-suppressed AIDS patient was suspected of suffering from BK virus (BKV) meningoencephalitis, after being studied for common causes of neurological complications of co-infectious origin. Polymerase chain reaction (PCR) and sequence analysis of cerebrospinal fluid and brain samples, confirmed the presence of BKV. His clinical condition improved along with the regression of brain lesions, after modifications on his antiretroviral regime. Five months after discharge, the patient was readmitted because of frequent headaches, and a marked inflammatory reaction was evidenced by a new magnetic resonance imaging (MRI). The symptoms paralleled a rising CD4+ lymphocyte count, and immune reconstitution syndrome was suspected. This is the first non-postmortem report of BKV meningoencephalitis in an AIDS patient, showing clinical and radiographic improvement solely under HAART.

Cerebral toxoplasmosis in HIV-positive patients in Brazil: clinical features and predictors of treatment response in the HAART era.

A prospective study of 55 confirmed or presumptive cases of cerebral toxoplasmosis in HIV positive patients in Brazil was performed to describe clinical characteristics and to identify predictive factors for clinical response to the anti-Toxoplasma treatment. Cerebral toxoplasmosis led to the diagnosis of HIV infection in 19 (35%) patients, whereas it was the AIDS defining disease in 41 (75%) patients. Of these, 22 (54%) patients were previously know to be HIV-positive. At diagnosis of cerebral toxoplasmosis, only 4 (7%) patients were on highly active antiretroviral therapy (HAART), and 6 (11%) were receiving primary cerebral toxoplasmosis prophylaxis. The mean CD4+ cell count was 64.2 (+/- 69.1) cells per microliter. Forty-nine patients (78%) showed alterations consistent with toxoplasmosis on brain computed tomography. At 6 weeks of treatment, 23 (42%) patients had complete clinical response, 25 (46%) partial response, and 7 (13%) died. Alteration of consciousness, Karnofsky score less than 70, psychomotor slowing, hemoglobin less than 12 mg/dL, mental confusion, Glasgow Coma Scale less than 12 were the main predictors of partial clinical response. All patients were placed on HAART within the first 4 weeks of diagnosis of cerebral toxoplasmosis. One year after the diagnosis, all available patients were on HAART and toxoplasmosis prophylaxis, and only 2 patients had relapse of cerebral toxoplasmosis. In Brazilian patients with AIDS, cerebral toxoplasmosis mainly occurs as an AIDS-defining disease, and causes significant morbidity and mortality. Signs of neurologic deterioration predict an unfavorable response to the treatment. Early start of HAART seems to be related to better survival and less relapses.

Cerebral aspergillosis due to Aspergillus fumigatus in AIDS patient: first culture-proven case reported in Brazil.

Cerebral aspergillosis is a rare cause of brain expansive lesion in AIDS patients. We report the first culture-proven case of brain abscess due to Aspergillus fumigatus in a Brazilian AIDS patient. The patient, a 26 year-old male with human immunodeficiency virus (HIV) infection and history of pulmonary tuberculosis and cerebral toxoplasmosis, had fever, cough, dyspnea, and two episodes of seizures. The brain computerized tomography (CT) showed a bi-parietal and parasagittal hypodense lesion with peripheral enhancement, and significant mass effect. There was started anti-Toxoplasma treatment. Three weeks later, the patient presented mental confusion, and a new brain CT evidenced increase in the lesion. He underwent brain biopsy, draining 10 mL of purulent material. The direct mycological examination revealed septated and hyaline hyphae. There was started amphotericin B deoxycholate. The culture of the material demonstrated presence of the Aspergillus fumigatus. The following two months, the patient was submitted to three surgeries, with insertion of drainage catheter and administration of amphotericin B intralesional. Three months after hospital admission, his neurological condition suffered discrete changes. However, he died due to intrahospital pneumonia. Brain abscess caused by Aspergillus fumigatus must be considered in the differential diagnosis of the brain expansive lesions in AIDS patients in Brazil.

Cerebral aspergillosis due to Aspergillus fumigatus in AIDS patient: first culture - proven case reported in Brazil

La aspergilosis cerebral es una causa rara de lesión expansiva cerebral en pacientes con SIDA. Presentamos el primer reporte de un absceso cerebral causado por Aspergillus fumigatus en un paciente brasileño con SIDA. El paciente, de 26 años de edad, presentaba antecedentes de infección por el virus de la inmunodeficiencia humana (VIH), tuberculosis pulmonar y toxoplasmosis cerebral. Manifestó fiebre, tos, disnea y dos episódios de convulsiones. La tomografía computadorizada (TC) demostró una lesión hipodensa parasagital y bi-parietal con realce periférico e importante efecto de masa. Se inició tratamiento anti-Toxoplasma. Tres semanas después, el paciente evidenció confusión mental y una nueva TC de cráneo mostró aumento de la lesión. Se realizó biopsia cerebral con drenaje de 10 mL de material purulento. El examen micológico directo reveló hifas hialinas septadas. Se inició anfotericina B deoxicolato. La cultura del material demostró presencia de Aspergillus fumigatus. En los siguientes dos meses el paciente fue sometido a otras tres cirugías, insertándose un catéter de drenaje y administrándose anfotericina B intralesional. Tres meses después de la admisión hospitalaria, la condición neurológica del paciente sufrió discretos cambios. Sin embargo, falleció debido a neumonia intrahospitalaria. Aunque muy raros, los abscesos cerebrales causados por Aspergillus fumigatus deben ser considerados en el diagnóstico diferencial de las lesiones expansivas cerebrales en pacientes con SIDA.