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Accessibility and Utilization of Programmed Outer Defibrillators inside Ny Express Schools.
BACKGROUND Candidemia is a common healthcare-associated bloodstream infection with high morbidity and mortality. There are no current estimates of candidemia burden in the United States. METHODS In 2017, the Centers for Disease Control and Prevention (CDC) conducted active population-based surveillance for candidemia through the Emerging Infections Program (EIP) in 45 counties in nine states encompassing ~17 million persons (5% of the national population). HDAC inhibitor Laboratories serving the catchment area population reported all blood cultures with Candida, and a standard case definition was applied to identify cases that occurred in surveillance area residents. Burden of cases and mortality was estimated by extrapolating surveillance area cases to national numbers using 2017 national census data. RESULTS We identified 1,226 candidemia cases across nine surveillance sites in 2017. Based on this, we estimated 22,660 (95% confidence interval [CI] 20,210-25,110) cases of candidemia occurred in the United States in 2017. Overall estimated incidence was 7.0 cases per 100,000 persons, with highest rates in adults ≥65 years (20.1/100,000), males (7.9/100,000), and those of black race (12.3/100,000). An estimated 3,380 (95% CI 1,318-5,442) deaths occurred within seven days of a positive Candida blood culture and 5,628 (95% CI 2,465-8,791) deaths occurred during the hospitalization with candidemia. CONCLUSIONS Our analysis highlights the substantial burden of candidemia in the U.S. Because candidemia is only one form of invasive candidiasis, the true burden of invasive infections due to Candida is higher. Ongoing surveillance can support future burden estimates and help assess the impact of prevention interventions. Published by Oxford University Press for the Infectious Diseases Society of America 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.Erdheim-Chester disease (ECD) is characterized by the infiltration of tissues by foamy CD68+CD1a- histiocytes, with 1500 known-cases since 1930. Mutations activating the MAPK pathway are found in more than 80% of ECD patients, mainly the BRAFV600E activating mutation in 57-70% of cases, followed by MAP2K1 in close to 20%. The discovery of BRAF mutations and of other MAP kinase pathway alterations, as well as the co-occurrence of ECD with LCH in 15% of ECD patients, led to the 2016 revision of the classification of histiocytoses in which LCH and ECD belong to the "L" group. Both conditions are considered inflammatory myeloid neoplasms. Ten percent of ECD cases are associated with myeloproliferative neoplasms and/or myelodysplastic syndromes. Some of the most striking signs of ECD are the long bone involvement (80-95%), as well as the 'hairy kidney' appearance on the CT-scan (63%), the "coated aorta" (40%), the right atrium pseudo-tumoral infiltration (36%). Central nervous system (CNS) involvement is a strong prognostic factor and independent predictor of death. Interferon-alpha seems to be the best initial treatment for ECD. Since 2012, more than 200 patients worldwide with multi-system or refractory ECD have benefitted from highly effective therapy with BRAF and MEK inhibitors. Targeted therapies have an overall, robust and reproducible efficacy in ECD, with no acquired resistance to date, but their use may be best reserved for the most severe manifestations of the disease, as they may be associated with serious side-effects and as yet unknown long-term consequences. Copyright © 2020 American Society of Hematology.INTRODUCTION Adipose tissue (AT) alterations are common in people living with HIV (PLWH). Decreases in AT density suggest disrupted adipocyte function/hypertrophy. We assessed changes in AT density after antiretroviral therapy (ART) initiation and associations with immuno-metabolic parameters. METHODS In a prospective randomized clinical trial of ART initiation, L4-L5 abdominal CT scans measured subcutaneous (SAT) and visceral (VAT) AT area and density in treatment-naïve PLWH randomized to tenofovir-emtricitabine plus atazanavir-ritonavir, darunavir-ritonavir, or raltegravir. Linear regression models compared weeks 0 (W0) and 96 (W96) levels, and 96-week changes, in SAT and VAT density (in Hounsfield units, HU). Spearman's correlations assessed relationships between AT density and immuno-metabolic parameters. RESULTS Participants (n=228) were 89% male and 44% white non-Hispanic. Median age was 36 years, baseline HIV-1 RNA 4.6 log10 copies/mL, and CD4+ T cell count 344 cells/mm3. Over 96 weeks, SAT and VAT HU decreased significantly in all arms. Less dense W96 SAT and VAT density correlated with higher HDL cholesterol and adiponectin (r=0.19 to 0.30) levels and lower IL-6, non-HDL cholesterol, triglyceride, leptin and HOMA-IR (r=-0.23 to -0.68) levels at W96 after adjusting for baseline CD4+ T cell count, HIV-1 RNA and baseline AT area. CONCLUSIONS Following virologic suppression, lower SAT and VAT density was associated with greater plasma measures of systemic inflammation, lipid disturbances and insulin resistance independent of AT area, suggesting changes in AT density with ART may lead to adverse health outcomes independent of AT quantity. © The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail [email protected] lymphohistiocytosis (HLH) is a syndrome describing patients with severe systemic hyperinflammation. Characteristic features include unremitting fever, cytopenias, hepatosplenomegaly, and elevation of typical HLH biomarkers. Patients can develop hepatitis, coagulopathy, liver failure, central nervous system involvement, multi-organ failure, and other manifestations. The syndrome has a high mortality rate. More and more, it is recognized that while HLH can be appropriately used as a broad summary diagnosis, many pediatric patients actually suffer from an expanding spectrum of genetic diseases that can be complicated by the syndrome of HLH. Classic genetic diseases in which HLH is a typical and common manifestation include pathogenic changes in the Familial HLH genes (PRF1, UNC13D, STXBP2, STX11), several granule/pigment abnormality genes (RAB27A, LYST, AP3B1), the X-linked lymphoproliferative disease genes (SH2D1A, XIAP), and others such as NLRC4, CDC42, and the EBV-susceptibility diseases. There are many other genetic diseases in which HLH is an infrequent complication of the disorder as opposed to a prominent manifestation of the disease caused directly by the genetic defect, including other primary immune deficiencies and inborn errors of metabolism. HLH can also occur in patients with underlying rheumatologic or autoinflammatory disorders, and is usually designated macrophage activation syndrome in those settings. Additionally, HLH can develop in patients during infections or malignancies without a known (or as yet identified) genetic predisposition. This article will attempt to summarize current concepts in the pediatric HLH field as well as offer a practical diagnostic and treatment overview. Copyright © 2020 American Society of Hematology.BACKGROUND Having a penicillin allergy label is associated with the use of less appropriate and more expensive antibiotics and increased healthcare utilization. link2 Penicillin allergy testing results in delabeling most allergy claimants and may be cost-saving. This study aimed to project whether penicillin allergy testing in patients reporting a penicillin allergy is cost-saving. METHODS In this economic evaluation study, we built decision models to project the economic impact of two strategies for the patient with a penicillin allergy label (1) Perform diagnostic testing (drug challenges, with or without skin tests) and (2) Do not perform diagnostic testing. The health service perspective was adopted, considering costs with penicillin allergy tests, and with hospital bed-days/outpatient visits, antibiotic use, and diagnostic testing. Twenty-four base case decision models were built, accounting for differences in the diagnostic workup, setting (inpatient versus outpatient) and geographic region. Uncertainty was explored via probabilistic sensitivity analyses. RESULTS Penicillin allergy testing was cost-saving in all decision models built. For models assessing the performance of both skin tests and drug challenges, allergy testing resulted in average savings of $657 for inpatients (United States of America $1444, Europe $489) and $2746 for outpatients (United States of America $256, Europe $6045). 75% of simulations obtained through probabilistic sensitivity analysis identified testing as the less costly option. CONCLUSION Penicillin allergy testing was projected to be cost-saving across different scenarios. These results are devised to inform guidelines, supporting the adoption of policies promoting widespread testing of patients with a penicillin allergy label. © The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail [email protected] Approximately 6% of children hospitalised with severe falciparum malaria in Africa are also bacteremic. It is therefore recommended that all children with severe malaria should receive broad spectrum antibiotics in addition to parenteral artesunate. Empirical antibiotics are not recommended currently for adults with severe malaria. METHODS Blood cultures were performed on sequential prospectively studied adult patients with strictly defined severe falciparum malaria admitted to a single referral centre in Vietnam between 1991 and 2003. RESULTS In 845 Vietnamese adults with severe falciparum malaria admission blood cultures were positive in 9 (1.07% 95%CI 0.37 to 1.76%); S. aureus 2, S. pyogenes 1, S. Typhi 3, Non-typhoid Salmonella 1, K. link3 pneumoniae 1, H. influenzae type b 1. Bacteremic patients presented usually with a combination of jaundice, acute renal failure and high malaria parasitemia. Four bacteremic patients died compared with 108 (12.9%) of 836 non-bacteremic severe malaria patients; risk ratio 3.44 (95%CI 1.62 to 7.29). In patients with >20% parasitemia the prevalence of concomitant bacteremia was 5.2% (4/76 95%CI 0.2 to 10.3%) compared with 0.65% (5/769 0.08 to 1.2%) in patients with less then 20% parasitemia, a risk ratio of 8.1 (2.2 to 29.5). CONCLUSIONS In contrast to children, the prevalence of concomitant bacteremia in adults with severe malaria is low. Administration of empirical antibiotics, in addition to artesunate, is warranted in the small subgroup of patients with very high parasitemias, emphasising the importance of quantitative blood smear microscopy assessment, but it is not indicated in the majority of adults with severe falciparum malaria. © The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America.BACKGROUND In addition to demonstrated public health benefits on reducing transmission, it remains unclear how early antiretroviral therapy (ART) must be started after HIV acquisition to maximize individual benefits. METHODS We conducted an open-label randomized clinical study in Lima, Peru among adult MSM and transgender women with acute (HIV-antibody negative/HIV-1 RNA positive) or recent (confirmed negative HIV-antibody or RNA test within three months) HIV infection, who were randomized to start ART immediately vs defer by 24 weeks. We evaluated outcomes by treatment arm, and immunologic markers by days since estimated date of detectible infection (EDDI). RESULTS Of 216 participants, 105 were assigned to immediate arm and 111 to deferred arm (median age 26.8 years, 37% with acute HIV). The incidence of non-ART-related adverse events was lower in immediate vs deferred arm (83 vs 123/100 person-years, IRR 0.67 (95%CI 0.47, 0.95; p=0.02), the difference dominated by fewer infections in those treated immediately.
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