Spatiotemporal dynamics and demographic profiles of imported Plasmodium falciparum and Plasmodium vivax infections in Ontario, Canada (1990-2009).

We examined malaria cases reported to Ontario's public health surveillance systems from 1990 through 2009 to determine how temporal scale (longitudinal, seasonal), spatial scale (provincial, health unit), and demography (gender, age) contribute to Plasmodium infection in Ontario travellers. Our retrospective study included 4,551 confirmed cases of imported malaria reported throughout Ontario, with additional analysis at the local health unit level (i.e., Ottawa, Peel, and Toronto). During the 20-year period, Plasmodium vivax accounted for 50.6% of all cases, P. falciparum (38.6%), Plasmodium sp. (6.0%), P. ovale (3.1%), and P. malariae (1.8%). During the first ten years of the study (1990-1999), P. vivax (64% of all cases) was the dominant agent, followed by P. falciparum (28%); however, during the second ten years (2000-2009) the situation reversed and P. falciparum (55%) dominated, followed by P. vivax (30%). The prevalence of P. falciparum and P. vivax cases varied spatially (e.g., P. falciparum more prevalent in Toronto, P. vivax more prevalent in Peel), temporally (e.g. P. falciparum incidence increased during the 20-year study), and demographically (e.g. preponderance of male cases). Infection rates per 100,000 international travellers were estimated: rates of infection were 2× higher in males compared to females; rates associated with travel to Africa were 37× higher compared to travel to Asia and 126× higher compared to travel to the Americas; rates of infection were 2.3-3.5× higher in June and July compared to October through March; and rates of infection were highest in those 65-69 years old. Where exposure country was reported, 71% of P. falciparum cases reported exposure in Ghana or Nigeria and 63% of P. vivax cases reported exposure in India. Our study provides insights toward improving pre-travel programs for Ontarians visiting malaria-endemic regions and underscores the changing epidemiology of imported malaria in the province.

Fluids and diuretics for acute ureteric colic.

BACKGROUND: Acute ureteric colic is commonly associated with severe and debilitating pain. Theoretically, increasing fluid flow through the affected kidney might expedite stone passage, thereby improving symptoms more quickly. The efficacy and safety of interventions such as high volume intravenous (IV) or oral fluids and diuretics aimed at expediting ureteric stone passage is, however, uncertain. OBJECTIVES: To look at the benefits and harms of diuretics and high volume (above maintenance) IV or oral fluid therapy for treating adult patients presenting with uncomplicated acute ureteric colic. SEARCH METHODS: We searched the Cochrane Renal Group's specialised register (3 January 2012). Previously we searched the Cochrane Central Register of Controlled Trials (CENTRAL The Cochrane Library), MEDLINE (from 1966), EMBASE (from 1980) and handsearched reference lists of nephrology and urology textbooks, review articles, relevant studies, and abstracts from nephrology scientific meetings. SELECTION CRITERIA: All randomised controlled trials (RCTs) and quasi-RCTs (including the first period of randomised cross-over studies) looking at diuretics or high volume IV or oral fluids for treating uncomplicated acute ureteric colic in adult patients presenting to the emergency department for the first time during that episode were included. DATA COLLECTION AND ANALYSIS: Two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random-effects model for multiple studies of the same outcomes, otherwise the fixed-effect model was used. Results were expressed as risk ratios (RR) for dichotomous outcomes or as mean differences (MD) for continuous data with 95% confidence intervals (CI). MAIN RESULTS: Two studies (enrolling 118 participants) examined the association between intense hydration and ureteric colic outcomes. There was no significant difference in pain at six hours (1 study, 60 participants: RR 1.06, 95% CI 0.71 to 1.57), surgical stone removal (1 study, 60 participants: RR 1.20, 95% CI 0.41 to 3.51) or manipulation by cystoscopy (1 study, 60 participants: RR 0.67, 95% CI 0.21 to 2.13) when no fluids over six hours was compared to three litres IV fluids administered over a six hour period. There was no difference in stone clearance (1 study 43 participants: RR 1.38, 95% CI 0.50 to 3.84), hourly pain score or patients' narcotic requirements (P > 0.05 for all comparisons) when forced IV hydration of two litres over four hours was compared with minimal IV hydration at 20 mL/hour.One study did not provide any details which would have allowed us to assess any of the risk of bias items (selection, detection, performance, attrition or reporting bias). The second study did not report the method of randomisation or allocation (selection bias - unclear), they reported that the patients were blinded to therapy (low risk of bias), analgesics were administered according to predetermined pain score criteria (low risk), and assessment of stone passage was unlikely to have been biased by knowledge of group assignment (low risk). However the second study also reported a high percentage of participants excluded post randomisation (26%; high risk of bias). We were unable to assess or ascertain any of the other risk of bias items. AUTHORS' CONCLUSIONS: We found no reliable evidence in the literature to support the use of diuretics and high volume fluid therapy for people with acute ureteric colic. However, given the potential positive therapeutic impact of fluids and diuretics to facilitate stone passage, the capacity of these interventions warrants further investigation to determine safety and efficacy profiles.

Biomarkers for predicting serious cardiac outcomes at 72 hours in patients presenting early after chest pain onset with symptoms of acute coronary syndromes.

BACKGROUND: Most outcome studies of patients presenting early to the emergency department with potential acute coronary syndromes have focused on either the index diagnosis of myocardial infarction (MI) or a composite end point at a later time frame (30 days or 1 year). We investigated the performance of 9 biomarkers for an early serious outcome. METHODS: Patients (n=186) who presented to the emergency department within 6 h of chest pain onset had their presentation serum sample measured for the following analytes: creatine kinase, creatine kinase isoenzyme MB, enhanced AccuTnI troponin I (Beckman Coulter), high-sensitivity cardiac troponin T (hs-cTnT), ischemia-modified albumin, interleukin-6, investigation use only hs-cTnI (Beckman Coulter), N-terminal pro-B-type natriuretic peptide, and cardiac troponin I (Abbott AxSym). We followed patients until 72 h after presentation and determined whether they experienced the following serious cardiac outcomes: MI, heart failure, serious arrhythmia, refractory ischemic cardiac pain, or death. ROC curves were analyzed to determine the area under the ROC curve (AUC) and optimal cutoffs for the biomarkers. RESULTS: The AUCs for the hs-cTnI assay (0.86; 95% CI, 0.76-0.96), the AccuTnI assay (0.86; 95% CI, 0.78-0.95), and the hs-cTnT assay (0.82; 95% CI, 0.71-0.94) assays were significantly higher than those for the other 6 assays (AUC values≤0.71 for the rest of the biomarkers, P<0.05). The ROC curve-derived optimal cutoffs were ≥19 ng/L (diagnostic sensitivity, 80%; specificity, 88%), ≥0.018 µg/L (diagnostic sensitivity, 75%; specificity, 86%), and ≥32 ng/L (diagnostic sensitivity, 68%; specificity, 92%) for the hs-cTnI, AccuTnI, and hs-cTnT assays, respectively. CONCLUSIONS: The optimal cutoffs for predicting serious cardiac outcomes in this low-risk population are different from the published 99th percentiles. Larger studies are required to verify these findings.

Prevalence and correlates of GB virus C infection in HIV-infected and HIV-uninfected pregnant women in Bangkok, Thailand.

GB virus C (GBV-C) is an apathogenic virus that has been shown to inhibit HIV replication. This study examined the prevalence and correlates of GBV-C infection and clearance in three cohorts of pregnant women in Thailand. The study population consisted of 1,719 (1,387 HIV-infected and 332 HIV-uninfected) women from three Bangkok perinatal HIV transmission studies. Stored blood was tested for GBV-C RNA, GBV-C antibody, and if RNA-positive, genotype. Risk factors associated with the prevalence of GBV-C infection (defined as presence of GBV-C RNA and/or antibody) and viral clearance (defined as presence of GBV-C antibody in the absence of RNA) among women with GBV-C infection were examined using multiple logistic regression. The prevalence of GBV-C infection was 33% among HIV-infected women and 15% among HIV-uninfected women. GBV-C infection was independently associated (AOR, 95% CI) with an increasing number of lifetime sexual partners (referent-1 partner, 2 partners [1.60, 1.22-2.08], 3-10 partners [1.92, 1.39-2.67], >10 partners [2.19, 1.33-3.62]); injection drug use (5.50, 2.12-14.2); and HIV infection (3.79, 2.58-5.59). Clearance of GBV-C RNA among women with evidence of GBV-C infection was independently associated with increasing age in years (referent <20, 20-29 [2.01, 1.06-3.79] and ≥30 [3.18, 1.53-6.60]), more than 10 lifetime sexual partners (3.05, 1.38-6.75), and HIV infection (0.29, 0.14-0.59). This study found that GBV-C infection is a common infection among Thai women and is associated with HIV infection and both sexual and parenteral risk behaviors.

Infection with hepatitis C virus among HIV-infected pregnant women in Thailand.

OBJECTIVE: The purpose of this study was to describe the epidemiology of coinfection with hepatitis C virus (HCV) and HIV among a cohort of pregnant Thai women. METHODS: Samples from 1771 pregnant women enrolled in three vertical transmission of HIV studies in Bangkok, Thailand, were tested for HCV. RESULTS: Among HIV-infected pregnant women, HCV seroprevelance was 3.8% and the active HCV infection rate was 3.0%. Among HIV-uninfected pregnant women, 0.3% were HCV-infected. Intravenous drug use by the woman was the factor most strongly associated with HCV seropositivity. Among 48 infants tested for HCV who were born to HIV/HCV coinfected women, two infants were HCV infected for an HCV transmission rate of 4.2% (95% 0.51-14.25%). CONCLUSIONS: HCV seroprevalence and perinatal transmission rates were low among this Thai cohort of HIV-infected pregnant women.