Serial testing for latent tuberculosis infection in transplant candidates: a retrospective review.

BACKGROUND: Accurately identifying latent tuberculosis (TB) infection (LTBI) in liver and renal transplant candidates is important because of the risks associated with both treatment of LTBI and reactivation of disease in this population. Many programs advocate yearly screening of patients awaiting organ transplantation. The reproducibility of serial interferon-gamma release assay (IGRA) testing in transplant candidates has not been studied. METHODS: We conducted a retrospective longitudinal study of patients listed for liver or kidney transplantation between January 1, 2005 and February 1, 2012 at the University of Illinois Medical Center at Chicago. Data collected included demographics, transplant type, IGRA results, treatment received, and mortality. RESULTS: The study population was comprised of 795 adults; 79 (10%) had at least 1 indeterminate result; indeterminate results were less common in men (P = 0.01) and more common in liver transplant candidates (P < 0.001). The reversion frequency was 27% with a rate of 158.1 reversions in 1000 person-years. A higher magnitude of initial TB response values was predictive of consistently positive results (P < 0.001). The conversion frequency was 15% with a rate of 82.6 conversions in 1000 person-years. Among those who converted, the values of the IGRA varied, with 48% having a TB response of <1 IU/mL, 41% 1-5 IU/mL, and only 10% >5 IU/mL. CONCLUSIONS: A significant number of conversions and reversions occur during serial IGRA testing of transplant candidates. Delineating true-positive converters from false-positives is an issue that warrants further study.

Latent tuberculosis in kidney and liver transplant patients: a review of treatment practices and outcomes.

BACKGROUND: The standard treatment of latent tuberculosis infection (LTBI) is associated with toxicities and data are limited on tolerability among patients with advanced organ disease listed for transplant. Alternate options are available, but they have yet to be studied in this population. METHODS: A retrospective review of the treatment of LTBI among kidney and/or liver transplant candidates was conducted to assess factors impacting therapy initiation, tolerability, and completion of therapy. RESULTS: Of 174 eligible patients, treatment of LTBI was initiated in 129, of which 91 were listed for kidney transplant and 38 were listed for liver or liver/kidney transplant. Infectious Diseases consultation was independently associated with treatment initiation when controlling for waitlisted organ and receipt of hemodialysis (odds ratio [OR] 81.14, 95% confidence interval [CI] 23.94-274.94, P < 0.001). Documented completion of first-line therapy was 47% overall, and 49% and 39%, respectively, among kidney and liver/kidney candidates (P = not significant). On multivariable analysis, controlling for baseline aspartate aminotransferase and waitlisted organ, first-line receipt of rifampin was associated with lower rates of treatment completion (OR 0.19, 95% CI 0.05-0.77, P = 0.02). CONCLUSION: Based on medical record documentation, completion of first-line therapy was <50% in this cohort, although this is likely an underestimate, as 34% of patients had no chart documentation that therapy was completed. Approximately 20% of patients did not complete first-line therapy because of adverse effects.

A multicenter study of histoplasmosis and blastomycosis after solid organ transplantation.

AIM: A review of the clinical presentation, diagnosis, treatment and outcomes of 30 solid organ transplant recipients (SOTRs) with histoplasmosis or blastomycosis from 3 Midwestern academic medical centers. BACKGROUND: The endemic fungal pathogens, Histoplasma capsulatum and Blastomyces dermatitidis, may cause severe infection in SOTRs. In this report, we describe the clinical presentation, diagnosis, treatment, and outcomes of these endemic fungal infections (EFIs) among SOTRs at 3 academic transplant centers. METHODS: A retrospective review was conducted of SOTRs with histoplasmosis or blastomycosis from 3 Midwestern medical centers in the United States. Data collected included demographics, immunosuppression, clinical presentation, method of diagnosis, antifungal treatment, response to therapy, and patient and graft survival. RESULTS: Between 1996 and 2008, 30 transplant recipients with histoplasmosis or blastomycosis were identified, giving a cumulative incidence of infection of 0.50% (30/5989); 73% of the study patients were renal transplant recipients, and the median time to disease onset after transplantation was 10.5 months. The lungs were the most common site of infection (83%), and 60% had disseminated disease. Urine antigen testing was positive in all patients in whom it was performed (23/23). Initial antifungal therapy consisted of amphotericin B in 70%, and 87% received azoles, typically itraconazole (83%). Two patients developed relapsed infection and 7 patients had graft failure after EFI. Overall mortality was 30%, with an attributable mortality of 13%. CONCLUSIONS: As in several previous single-center studies, the incidence of post-transplant histoplasmosis and blastomycosis was <1%, but often resulted in disseminated infection. In this cohort, EFI was associated with a high rate of allograft loss and overall mortality.

Gastrointestinal tuberculosis in renal transplant recipients: case report and review of the literature.

Mycobacterium tuberculosis is an important opportunistic pathogen following renal transplantation and is often associated with adverse outcomes. Gastrointestinal tuberculosis (GITB) is an infrequent manifestation of TB but a potentially lethal one. We present a case of a renal allograft recipient with GITB 18 months after transplant and review other published cases to identify the typical presenting symptoms, risk factors, and natural history. Treatment of GITB is also discussed.

Unusual presentation of cytomegalovirus enteritis after liver and kidney transplantation.

Cytomegalovirus (CMV) is a cause of significant morbidity and mortality in solid organ transplant recipients. Gastrointestinal (GI) tract infection by CMV in this population can cause symptomatic disease, which typically manifests as fever, abdominal pain, nausea, and bloody diarrhea. Erosive lesions of the GI mucosa are often evident on endoscopic exam. We report an unusual presentation of CMV enteritis in a kidney and liver transplant recipient with the development of acute onset voluminous watery diarrhea in the absence of other typical symptoms and subsequent progression to hypovolemic shock and acute renal failure. This case emphasizes the atypical presentations of common opportunistic infections that may occur in immunosuppressed hosts.

Risk factors for wound healing complications in sirolimus-treated renal transplant recipients.

Impaired surgical site healing occurs in 20% to 50% of sirolimus (SRL)-treated renal transplant (RT) recipients, with most patients having received concomitant corticosteroids. We determined the incidence of surgical site complications among RT recipients receiving SRL with mycophenolate mofetil (MMF), with most patients on a steroid-avoidance protocol. SRL/MMF patients with complications within 3 months of transplantation were compared with 1) SRL/MMF patients without them and 2) matched RT recipients receiving tacrolimus (FK)/MMF. Between January 2002 and March 2005, 44 of 300 (15%) RT recipients received SRL within 6 weeks of transplantation. Fourteen (31.8%) developed lymphocele, bladder leak, wound dehiscence, cellulitis, or an abscess. Obesity (BMI > or =30 kg/m2) was significantly associated with problems: the mean BMI of SRL cases with complications was 29.9 kg/m2 vs 25.4 kg/m2 for SRL patients without them (P = .047). Seventy-one percent of obese SRL patients experienced complications compared with 24.3% (P = .025) of non-obese SRL patients. Surgical treatment was required in 29% of patients. Rates of maintenance steroid use were similar in SRL complicated cases compared with SRL patients without them. The FK control group showed a lower rate of complications (14.3%; P = .163) despite similar BMI, rejection rates, and chronic steroid use as the SRL group. Obesity and graft rejection were independent predictors of complications. Thus, among a group of predominantly steroid-free recipients on SRL, the rates of wound complications were similar to those seen previously, but the highest risk for them was observed in obese recipients and in those with acute rejection episodes. Wound complications were associated with significant morbidity.

Limitations of current antiretroviral agents and opportunities for development.

Significant progress has been made in the field of human immunodeficiency virus (HIV) pharmacotherapy. This is a remarkable achievement given that the virus was first recognized in the United States in 1981 and the first antiretroviral (ARV) agent became available in 1987. There are now 20 medications in 4 different classes approved by the Food and Drug Administration (FDA) for the treatment of HIV and the carefully orchestrated use of these agents has dramatically decreased HIV mortality. However, the currently available agents have concerning limitations. These include potentially life-threatening side effects, drug interactions, loss of effectiveness over time due to resistance and the need for an extremely high level of medication adherence to achieve viral suppression. In the following review, important features of the presently available agents are described, and the characteristics of an ideal ARV agent defined.

A multivariate analysis of the revised Conners' Teacher Rating Scale with low-income, urban preschool children.

The present investigation addressed the utility of the revised Conners' Teachers Rating Scale (CTRS-28) with low-income urban preschool children. CTRS-28 ratings for a large sample of preschool children from an urban Head Start program were analyzed using exploratory factor analysis. Analyses yielded a 3-factor structure: Conduct problems, Hyperactivity, and Passivity. Further analyses cross-validated this structure for males and females and supported its integrity. Multimethod, multisource validity analyses substantiated the CTRS-28 dimensions. The Play Disruption factor of the parent and teacher Penn Interactive Peer Play Scales (PIPPS) provided convergent validity for the Conduct and Hyperactivity factors of the CTRS-28, whereas the Play Interaction factor revealed divergent validity. The Play Disconnection factor of the PIPPS validated the CTRS-28 Passivity factor. The Q-Sort Emotional Regulation scale provided divergent validity for the Conduct and Hyperactivity factors and likewise the Q-Sort Autonomy scale provided divergent validity for the Passivity factor. Age and sex differences were assessed across the 3 factors of the derived preschool structure. A main effect was found for sex and age indicating that boys displayed higher levels of Hyperactivity and Passivity problems than girls did. Similarly, 4-year-old children demonstrated higher levels of Passivity problems than did 5-year-old children.

Streptococcus suis toxic-shock syndrome and meningitis.

Three cases with S. suis bacteremia and meningitis were reported. The first case was a 23-year-old butcher who was a regular drinker of alcohol for two years and developed streptococcal toxic-shock syndrome. The organism was transmitted to him through a minor cut in his right arm. The second cases was a 49-year-old female laborer who had been consuming locally produced alcohol for 20 years and developed fever and meningitis. Unfortunately, she succumbed in seven days despite intensive supportive and cefotaxime treatments. The third case was a 45-year-old regular alcoholic drinker and car painter who was seen at a private hospital due to contusion at his left lateral chest wall. However, fever and confusion due to meningitis was detected upon admission. Irreversible deafness developed within 48 hours of ceftriaxone therapy for meningitis. He finally recovered with deafness. S. suis was isolated from blood and cerebrospinal fluid cultures in all three cases though initially reported to be viridans group of streptococci.

Susceptibility patterns of clinical bacterial isolates in nineteen selected hospitals in Thailand.

Susceptibility patterns of 3,115 clinical isolates obtained from blood, urine, sputum and pus in 19 hospitals located in each part of Thailand, were studied using ampicillin, ampicillin plus sulbactam, piperacillin, gentamicin, amikacin, cefazolin, cefuroxime, cefotaxime, ceftazidime, ofloxacin and imipenem. E.coli, S.aureus, P. aeruginosa, Klebsiella spp., Acinetobacter spp., Proteus spp. and Salmonella spp., were the seven most common isolates and accounted for 28.3, 15.3, 14.6, 14.5, 5.2, 3.3 and 3.3 per cent of total isolates respectively. Susceptibility percentages of common bacterial isolates from blood to third-generation cephalosporins, amikacin, ofloxacin and imipenem were satisfactory and higher than those of clinical isolates from other specimens. As expected, nosocomial strains were more resistant than community-acquired strains. Isolates from government hospitals were more resistant to gentamicin and amikacin but more susceptible to ampicillin compared with those from private hospitals. Susceptibility to imipenem among isolates from private hospitals was less but did not reach statistical significance.

Swing beds: a strategy in rural hospitals' fight to survive.

More rural hospitals now have the opportunity to offer long-term care services under the expanded Federal swing-bed program. The ability to use inpatient beds for acute care or skilled nursing care can, in many cases, help rural hospitals improve their occupancy levels and increase revenues. However, hospitals must be aware of the need to closely monitor costs.

Win/win: urban and rural hospitals network for survival.

In an increasingly competitive, regulated, and politicized environment, the future of small or rural hospitals must rely on an organizational affiliation with an urban multihospital system to optimized opportunities for survival. Development and implementation of a small or rural hospital's affiliation with an urban multihospital system may provide necessary support and strength to survive as an independent entity, avoid mergers and acquisitions from investor-owned systems, and incorporate technical assistance and access to the resources of large, urban "lead" hospitals. Diversification into long-term and alternative care services will provide the foundation for hospital-wide survival through adaptation of alternative delivery plans to both the public and private sectors. Networking, whether through a formal or informal structure, may provide both urban and rural, large and small hospitals, with the only opportunity for survival in the 1980s and beyond. Networking gives hospitals an opportunity to develop symbiotic relationships with previously competing institutions for physicians, services, and patients. Networking solidifies missions, goals, and objectives for healthcare delivery systems and produces a win/win situation for everyone. It may be a legal entity (a corporate structure) or an informal affiliation among like groups of providers. A discussion of networking is provided for consideration by hospitals currently evaluating options in the multihospital systems arena.

Effects of selected cholinergic and anticholinergic drugs on Brugia malayi (Nematoda).

1. Several drugs were tested as inhibitors of the body movements of adult Brugia malayi. 2. Atropine, carbachol, DDNS (a fluorescent acetylcholine analog), diethylcarbamazine, and physostigmine caused significant reduction in motor activity. 3. Glutamate, hexamethonium, muscarine, norepinephrine, serotonin and d-tubocurarine had no effect. Three novel phosphonium compounds were tested as inhibitors of Brugia and vertebrate acetylcholinesterase. 4. Two of these produced preferential inhibition of the enzyme from Brugia.

Effects of phosphonium compounds on Schistosoma mansoni.

A new series of phosphonium salts was examined for effects on the cholinergic nervous system of Schistosoma mansoni. Studies were conducted using both an activity-monitoring and fluorescent-labeling technique. The activity method gave more definitive results, indicating that some poly(methylene)bis(triphenylphosphonium) salts and some [3-(alkylamino)propyl]triphenylphosphonium salts have strong anticholinergic effects. Hexyltriphenylphosphonium bromide has very marked effects both in the motility and the fluorescence test, but these effects cannot immediately be ascribed to cholinergic actions.