TB disease patterns by HIV and diabetes status.

BACKGROUND: TB is commonly categorised as pulmonary (PTB) or extrapulmonary TB (EPTB). Knowledge of TB disease patterns (PTB and/or EPTB) and determining risk factors remains limited.METHODS: This was a prospective cohort study using point-of-care ultrasound (POCUS) in Indian patients with presumed TB. Clinical and imaging data were used to develop refined case definitions for PTB, concurrent PTB and EPTB (PTB + EPTB) and EPTB without PTB (EPTB). These groups were analysed by HIV (HIV+/-) and diabetes mellitus (DM+/-) status.RESULTS: Of 172 HIV-/DM- patients with TB, 48% had PTB, 23% PTB + EPTB and 29% had EPTB, totalling 52% with any EPTB (PTB + EPTB or EPTB). In HIV+/DM- patients with TB (n = 35), 6% had PTB, 40% had PTB + EPTB and 54% had EPTB, accounting for 94% with EPTB. In HIV-/DM+ patients with TB (n = 61), 61% had PTB, 28% had PTB + EPTB and 11% had EPTB, representing 39% with EPTB.CONCLUSION: Refined case definitions revealed high proportions of EPTB even without HIV or DM. HIV further altered the TB disease pattern towards EPTB and DM towards PTB. Therefore, the dichotomy between PTB or EPTB does not represent the actual spectrum of TB disease. EPTB should receive higher priority in research and clinical practice.

Cure with ledipasvir/sofosbuvir for chronic hepatitis C virus in an individual with gastric bypass.

WHAT IS KNOWN AND OBJECTIVE: The impact of gastric bypass surgery on the pharmacokinetics of various medications has been reported. Presently, no data exist for the treatment of chronic hepatitis C virus with ledipasvir/sofosbuvir (LDV/SOF) in an individual with a history of gastric bypass. CASE DESCRIPTION: We report the successful cure of an individual who was treated with LDV/SOF who had a history of gastric bypass. The patient tolerated LDV/SOF well while only experiencing a minor headache. WHAT IS NEW AND CONCLUSION: Ledipasvir/sofosbuvir treatment may still be effective in those with a history of gastric bypass surgery.

Immune thrombocytopenia secondary to tuberculosis: a case and review of literature.

Immune thrombocytopenia (ITP) is an auto-immune condition that results in isolated thrombocytopenia associated with possibly lethal haemorrhage. In its secondary form, ITP can be triggered by many infectious and non-infectious conditions. Secondary ITP associated with tuberculosis (TB) has rarely been described in the literature. We report on a 22-year-old patient presenting with hypermenorrhoea and petechiae due to ITP secondary to tuberculous lymphadenitis. Normalisation of thrombocytopenia was only achieved after initiation of anti-tuberculosis treatment following failure of thrombocyte substitution and immune-modulatory treatment. A search of the literature available on TB-associated ITP identified 50 cases published between 1964 and 2016. We reviewed all cases using suggested case definitions on the likelihood of association between ITP and TB. A broad spectrum of TB sites was reported to be associated with ITP, and anti-tuberculosis treatment was the most effective therapy for platelet count normalisation. Time from initiation of anti-tuberculosis treatment to platelet count recovery ranged from 2 days to 3 months. In endemic regions, TB should be considered as an underlying cause of ITP. Early diagnosis of TB and initiation of anti-tuberculosis treatment appears crucial for rapid platelet count recovery, and can reduce the risks associated with long-term immunosuppression, transfusions and the time at risk for haemorrhage.

Rating of perceived exertion and heart rate as indicators of exercise intensity in different environmental temperatures.

This study examined the validity of rating of perceived exertion (RPE) and heart rate (HR) obtained during incremental exercise (INC) as indicators of intensity during constant load exercise (CL). Nine cyclists (VO2max = 53.3 +/- 8.9 ml.kg-1.min-1) performed INC to determine intensity at the onset of blood lactate accumulation (OBLA). Three CL work bouts at OBLA were performed in an environmental chamber with temperatures (30 degrees C, 22 degrees C, 14 degrees C) randomly assigned. RPE and HR were determined every 5 min. Data during CL from initial 5 min (5 MIN), second 5 min (10 MIN), midpoint (MID), and exhaustion (END) were used in treatment by time ANOVA to examine differences between temperature conditions, with repeated measures ANOVA testing for differences between INC and CL. Tukey HSD post-hoc tests identified mean differences, with significance set at P < or = 0.01. No significant differences across temperature conditions for RPE or HR were found. RPE obtained at OBLA during INC (13.7 +/- 0.9) was significantly different from 5 MIN, 10 MIN, MID, and END during CL in all temperatures. HR obtained at OBLA during INC (165.4 +/- 12.3 bpm) was significantly higher than 5 MIN for all temperatures (30 degrees C = 153.0 +/- 9.9; 22 degrees C = 151.0 +/- 11.8; 14 degrees C = 150.2 +/- 13.8), but was not significantly different from INC for 10 MIN, MID, or END measures. The data indicate HR is a more valid marker of exercise intensity than RPE.

Interaction of granulocytopenia and construction activity as risk factors for nosocomial invasive filamentous fungal disease in patients with hematologic disorders.

A clinicoepidemiologic study was undertaken to investigate an apparent increase in frequency of nosocomial invasive filamentous fungal disease (NIFFD) in adult patients with acute leukemia hospitalized during a period of hospital construction, and to determine if a relationship existed between the construction activity and the acquisition of NIFFD. The first study goal, to determine the incidence of NIFFD before and during construction, was approached by calculation of incidence rates of NIFFD in patients with acute leukemia, comparing 1982 and 1983 (a baseline period free of construction) to 1986 (a year when construction activity was at its peak). The second study goal, to identify risk factors for the development of NIFFD, was accomplished by reviewing the autopsy records of all patients with underlying hematologic disorders accompanied by granulocytopenia who died in our hospital from 1982 through 1986. Patients with and without autopsy evidence of NIFFD were then compared by univariate and multivariate (logistic regression) analysis to identify potential risk factors for the acquisition of NIFFD. The incidence of NIFFD in patients with acute leukemia hospitalized during the period of hospital construction was significantly increased when compared to a baseline period without construction (11 per 139 versus 4 per 333, p less than .001). Review of all granulocytopenic patients autopsied over the five-year interval 1982 through 1986 revealed duration of granulocytopenia and hospitalization during construction to be risk factors for NIFFD by univariate analysis (p less than .005). Logistic regression showed duration of granulocytopenia to be highly significant independent risk factor (p less than .01) and construction activity to be a probable independent risk factor (p = .09).(ABSTRACT TRUNCATED AT 250 WORDS)

Invasive Aspergillus infections complicating coronary artery bypass grafting.

Endovascular infection with Aspergillus species results in unacceptably high mortality of greater than 80% in most series. Failure to recognize the infection early during its clinical course contributes to its formidable lethality. Blood cultures almost never reveal organisms, as in our Cases 1 and 2. When considering a patient with fever, changing murmur, major systemic emboli, or splenomegaly, and with blood cultures negative for organisms months or even years after cardiac surgery, therefore, the physician should maintain a high index of suspicion for fungal endocarditis. The best opportunity to establish the diagnosis antemortem rests in careful histopathologic and microbiologic examination of infected emboli and vegetations. Most authors agree that a combined approach employing early valve replacement and aggressive antifungal chemotherapy with amphotericin B and perhaps flucytosine or rifampin represents the best option for treatment of endovascular Aspergillus infections.

Prospective, randomized comparison of sequential intravenous followed by oral ciprofloxacin with intravenous ceftazidime in the treatment of serious infections.

In a prospective, comparative trial, 47 hospitalized patients with serious infections that required parenteral antibiotic therapy were randomly assigned to receive either ciprofloxacin (200 mg every 12 hours intravenously followed by 500 mg every 12 hours orally at a time dependent on the patients' clinical and bacteriologic responses) or ceftazidime (2 g every eight to 12 hours intravenously). All evaluable subjects (39 patients) had documented infections, 23 percent of which were associated with bacteremia. The mean/median duration of intravenous antibiotic use for ciprofloxacin was 7.37/five days and for ceftazidime 9.95/seven days; 63 percent of the ciprofloxacin patients received an additional 17 days of oral therapy with ciprofloxacin, whereas intravenous therapy with ceftazidime was followed by an average of 12 days of an oral regimen in 55 percent of patients. Overall response rates for patients receiving ciprofloxacin and ceftazidime were 76 percent (16 of 21) and 82 percent (18 of 22), respectively. Four out of five bacteremias in each group were successfully treated. Overall, 69 percent of the pathogens were gram-negative aerobes, and 47 percent of the infections involved the urinary tract. Failure of therapy was most often associated with pneumonia (two of five failures with ciprofloxacin and three of four failures with ceftazidime). Adverse effects occurred in approximately 20 percent of patients in each group and were mild and reversible. Superinfections occurred in five of 19 (26 percent) ciprofloxacin recipients and seven of 20 (35 percent) ceftazidime recipients. All fungal superinfections involved the genitourinary tract and occurred most often in association with chronic indwelling catheters. Enterococcal superinfections occurred in both groups (a bacteremic urinary tract infection in a ceftazidime patient and osteomyelitis in a ciprofloxacin patient). Clostridium difficile-associated diarrhea was documented in a ceftazidime recipient. The mean duration of hospitalization following the onset of antibiotic treatment was 10.45 days in the ciprofloxacin group and 12.95 days in the ceftazidime group. Sequential intravenous/oral ciprofloxacin was as safe and effective as intravenous ceftazidime in the treatment of infections due to susceptible gram-positive and gram-negative organisms.

Risk factors for victimization during the 1980 riot at the Penitentiary of New Mexico.

The New Mexico Penitentiary riot of February 2, 1980, resulted in death for 33 inmates at the hands of their fellow prisoners, and the hospitalization of 62 inmates for treatment of drug overdose or trauma. A case-control study of dead and hospitalized inmates was conducted to determine risk factors for victimization. Twelve (12.5%) of the 96 inmates housed in the protective custody unit were killed, compared with an overall penitentiary death rate of 2.9% (p = 0.0003). These 12 individuals were similar to the general inmate population with respect to age, race, years of education, crimes, time served, and prison rule infractions committed. In contrast, the 21 homicide victims housed in other areas were younger and had committed significantly greater numbers of rule infractions during incarceration. Prisoners hospitalized for drug overdose, but not those hospitalized for traumatic injuries, could be differentiated from the remaining prison population by increased convictions for homicide and higher prison infraction rates. Inmates in protective custody were targeted selectively for death; other subgroups of victims of violence appear to share characteristics often associated with perpetrators of violence.