Disseminated Histoplasmosis in HIV-Infected Patients in South America: A Neglected Killer Continues on Its Rampage.

International audienc

Histoplasmose disseminada na América do Sul, o elefante invisível Central e o ponto cego letal de organizações internacionais de saúde

Centre Hospitalier de Cayenne. Centre d Investigation Clinique Antilles. Guyane, Cayenne.Centre Hospitalier de Cayenne. Centre d Investigation Clinique Antilles. Guyane, Cayenne.Asociación de Salud Integral. Clínica Familiar "Luis Angel García". Guatemala.Asociación de Salud Integral. Clínica Familiar "Luis Angel García". Guatemala.Asociación de Salud Integral. Clínica Familiar "Luis Angel García". Guatemala.Universidad Rosario. School of Medicine and Health Sciences. Bogotá and Corporacion para Investigationnes Biologicas. Bogotá, Colombia.Universidad Rosario. School of Medicine and Health Sciences. Bogotá and Corporacion para Investigationnes Biologicas. Bogotá, ColombiaUniversidad Rosario. School of Medicine and Health Sciences. Bogotá and Corporacion para Investigationnes Biologicas. Bogotá, Colombia.Ministério da Saúde. Secretaria de Vigilância em Saúde. Instituto Evandro Chagas. Ananindeua, PA, Brasil.Ministério da Saúde. Secretaria de Vigilância em Saúde. Instituto Evandro Chagas. Ananindeua, PA, Brasil.Fundação Oswaldo Cruz. Instituto de Pesquisa Clínica Evandro Chagas. Laboratório de Micologia. Rio de Janeiro, RJ, Brazil.Federal University of Ceará. Fortaleza, CE, Brazil.Laboratório Central de Saúde Pública do Amapá. Macapá, AP, Brazil.Laboratório Central de Saúde Pública do Amapá. Macapá, AP, Brazil.Laboratório Central de Saúde Pública do Amapá. Macapá, AP, Brazil.Academic Hospital Paramaribo. Suriname.Diakonessenhuis. Utrecht, KE.Academic Hospital Paramaribo. Suriname.Academic Hospital Paramaribo. Suriname.Université de Guyane. Ecosystèmes Amazoniens et Pathologie Tropicale. French Guiana.Université de Guyane. Ecosystèmes Amazoniens et Pathologie Tropicale. French Guiana.Université de Guyane. Ecosystèmes Amazoniens et Pathologie Tropicale. French Guiana.Centre Hospitalier de l Ouest Guyanais. Service de Médecine. French Guiana.Instituto Nacional de Higiene Rafael Rangel. Departamento de Micología. Caracas, Venezuela.Instituto Nacional de Higiene Rafael Rangel. Departamento de Micología. Caracas, Venezuela.INEI-ANLIS "Dr Carlos G. Malbran". Buenos Aires, Argentina.Fundação Oswaldo Cruz. Instituto Leônidas e Maria Deane. Rio de Janeiro, RJ, Brazil.Université de Guyane. Ecosystèmes Amazoniens et Pathologie Tropicale. French Guiana.Universidad Rosario. School of Medicine and Health Sciences. Bogotá and Corporacion para Investigationnes Biologicas. Bogotá, Colombia

Baseline Characteristics and Risk Profiles of Participants in the ISCHEMIA Randomized Clinical Trial

Importance: It is unknown whether coronary revascularization, when added to optimal medical therapy, improves prognosis in patients with stable ischemic heart disease (SIHD) at increased risk of cardiovascular events owing to moderate or severe ischemia. Objective: To describe baseline characteristics of participants enrolled and randomized in the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial and to evaluate whether qualification by stress imaging or nonimaging exercise tolerance test (ETT) influenced risk profiles. Design, Setting, and Participants: The ISCHEMIA trial recruited patients with SIHD with moderate or severe ischemia on stress testing. Blinded coronary computed tomography angiography was performed in most participants and reviewed by a core laboratory to exclude left main stenosis of at least 50% or no obstructive coronary artery disease (CAD) (<50% for imaging stress test and <70% for ETT). The study included 341 enrolling sites (320 randomizing) in 38 countries and patients with SIHD and moderate or severe ischemia on stress testing. Data presented were extracted on December 17, 2018. Main Outcomes and Measures: Enrolled, excluded, and randomized participants' baseline characteristics. No clinical outcomes are reported. Results: A total of 8518 patients were enrolled, and 5179 were randomized. Common reasons for exclusion were core laboratory determination of insufficient ischemia, unprotected left main stenosis of at least 50%, or no stenosis that met study obstructive CAD criteria on study coronary computed tomography angiography. Randomized participants had a median age of 64 years, with 1168 women (22.6%), 1726 nonwhite participants (33.7%), 748 Hispanic participants (15.5%), 2122 with diabetes (41.0%), and 4643 with a history of angina (89.7%). Among the 3909 participants randomized after stress imaging, core laboratory assessment of ischemia severity (in 3901 participants) was severe in 1748 (44.8%), moderate in 1600 (41.0%), mild in 317 (8.1%) and none or uninterpretable in 236 (6.0%), Among the 1270 participants who were randomized after nonimaging ETT, core laboratory determination of ischemia severity (in 1266 participants) was severe (an eligibility criterion) in 1051 (83.0%), moderate in 101 (8.0%), mild in 34 (2.7%) and none or uninterpretable in 80 (6.3%). Among the 3912 of 5179 randomized participants who underwent coronary computed tomography angiography, 79.0% had multivessel CAD (n = 2679 of 3390) and 86.8% had left anterior descending (LAD) stenosis (n = 3190 of 3677) (proximal in 46.8% [n = 1749 of 3739]). Participants undergoing ETT had greater frequency of 3-vessel CAD, LAD, and proximal LAD stenosis than participants undergoing stress imaging. Conclusions and Relevance: The ISCHEMIA trial randomized an SIHD population with moderate or severe ischemia on stress testing, of whom most had multivessel CAD