Delayed diagnosis of extrapulmonary tuberculosis in a 32-year-old man with knee pain

A 32-year-old Bangladeshi male was admitted at our emergency department for trauma of the left knee. The radiographs showed absence of fracture, and presence of an indeterminate oval lucency in the proximal tibia. Further examinations were suggested, but the patient refused. 6 months later, the patient re-presented at our emergency department. A CT scan showed progression of musculoskeletal involvement and spread to the liver. This case underlines the importance of considering tuberculosis in the differential diagnosis of indeterminate bone lesions in immigrant patients

REVISITING ANTHROPOZOONOSES IN THE MEDITERRANEAN BASIN. A SINGLE-CENTRE PERSPECTIVE. A SOUTHERN ITALIAN EXPERIENCE

Zoonoses, often better defined with the term anthropozoonoses, are diseases that can be transmitted to humans either by direct contact with animals or through arthropod vector intervention. Microbial interaction between humans and animals constitutes an important public health challenge, particularly in the Mediterranean basin. The main reasons this challenge is still relevant today include the phenomenon of migration, of both humans and animals, and climate change, which tend to alter the geographical distribution of zoonosis or the zoonotic agent, as well as the distribution range of potential vectors. The Mediterranean area seems to be affected by plentiful and widely distributed zoonoses, the main diseases being rickettsiosis, leishmaniasis, brucellosis, hydatid disease and viral zoonoses. The aim of this study is to revisit the prevalence and main clinical features of anthropozoonoses observed at the Department of Sciences for Health Promotion and Mother & Child Care, University of Palermo, Sicily, Southern Italy

Least squares optimization: From theory to practice

Nowadays, Nonlinear Least-Squares embodies the foundation of many Robotics and Computer Vision systems. The research community deeply investigated this topic in the last few years, and this resulted in the development of several open-source solvers to approach constantly increasing classes of problems. In this work, we propose a unified methodology to design and develop efficient Least-Squares Optimization algorithms, focusing on the structures and patterns of each specific domain. Furthermore, we present a novel open-source optimization system that addresses problems transparently with a different structure and designed to be easy to extend. The system is written in modern C++ and runs efficiently on embedded systemsWe validated our approach by conducting comparative experiments on several problems using standard datasets. The results show that our system achieves state-of-the-art performances in all tested scenarios

Surgical pathology and the diagnosis of invasive visceral yeast infection: two case reports and literature review

Invasive mycoses are life-threatening opportunistic infections that have recently emerged as a cause of morbidity and mortality following general and gastrointestinal surgery. Candida species are the main fungal strains of gut flora. Gastrointestinal tract surgery might lead to mucosal disruption and cause Candida spp. to disseminate in the bloodstream. Here we report and discuss the peculiar clinical and morphological presentation of two cases of gastrointestinal Candida albicans lesions in patients who underwent abdominal surgery. Although in the majority of cases reported in the literature, diagnosis was made on the basis of microbiological criteria, we suggest that morphological features of fungi in histological sections of appropriate surgical specimens could help to detect the degree of yeast colonization and identify patients at risk of developing severe abdominal Candida infection. Better prevention and early antifungal treatments are highlighted, and relevant scientific literature is reviewed

Behavioral and clinical characteristics of people receiving medical care for HIV infection in an outpatient facility in Sicily, Italy

Aim: The authors examined a cohort of HIV-positive outpatients at the AIDS Center of Palermo University in Italy in order to identify factors related to the frequency of their visits to the outpatient facility for health care services. Methods: Two hundred and twenty-four HIV-infected subjects were enrolled in the study. Demographic and HIV disease characteristics were recorded and assessed with the number of days accessed to our outpatients unit in univariate and multivariate analyses. The potential relationship with immunological status was also analyzed stratifying the patients into groups according to their CD4+ T-cell counts ( 65500 vs, \u2c2500/mm3, and 65200 vs < 200/mm3). Results: Both univariate and multivariate analyses showed that duration of antiretroviral therapy, \u2c25 years and hypertension were significantly associated with a CD4+ T-cell count of, \u2c2500/mm3, whereas geographic origin (Africa) was associated with a CD4+ T-cell count of, \u2c2200/mm3. Mean number of days the patients sought access to day-care services for laboratory tests was negatively associated with CD4+ T-cell count. Conclusion: Patients with low CD4+ T-cell counts showed higher use of health care services, demonstrating how early HIV diagnosis can help to reduce health care costs. The CD4+ T-cell cut-off of 200 cells emphasizes the importance of identifying and managing HIV infection among hard-to-reach groups like vulnerable migrants. In our sle, the illegal status of immigrants does not influence the management of their HIV/AIDS condition, but the lack of European health card that documents the current antiretroviral status, could interfere with the efforts to eradicate AIDS. A better understanding of the major determinants of HIV treatment costs has led to appropriate large-scale actions, which in turn has increased resources and expanded intervention programs. Further guidance should be offered to hard-to-reach groups in order to improve early AIDS diagnosis, and procedures for identifying and managing these vulnerable subjects should be made available to care commissioners and service providers

Monocyte to lymphocyte blood ratio in tuberculosis and HIV patients: Comparative analysis, preliminary data

Recent data confirmed the hypothesis suggested by historical studies that the ratio of peripheral blood monocytes to lymphocytes (M/L) is associated with the risk of tuberculosis (TB) disease. We retrospectively analyzed the electronic health records of tuberculosis and HIV-positive patients who had followed day-care programs at the AIDS Center of the University of Palermo, Italy. 261 patients were recruited and divided into 6 groups as follows: healthy control group (HCG: 47 pts), latent HIV negative infected TB group (LIG, 43 pts), active HIV negative tuberculosis (TAG: 61 pts), treated tuberculosis HIV negative (TTG: 44 pts), HIV drug-naive patients tested TST and QFT-IT-negative with negative chest x-Ray (HIVnG: 44 pts), and HIV-tuberculosis coinfection (HIVTB-G: 22 pts). For each group, absolute lymphocyte (L), monocyte (M) and M/L ratio by peripheral blood was calculated. The mean value of monocytes in the TAG group was significant, the highest (0.70\uc2\ub10.37 1x103/\uce\ubcl) in comparison to HGC (0.70&gt;0.44, p-value &lt;0.05), HIVnG (0.70&gt;0.40, p-value &lt;0.05) and HIVTB-G (0.70&gt;0.45, p-value&lt;0.05). Monocyte to lymphocyte blood RATIO showed a significant difference between groups (p-value &lt;0.001). In particular, the mean score of M/L ratio was higher in the TAG group compared to the HGC (0.49&gt;0.27, p-value&lt;0.05), LIG (0.49&gt;0.29, p-value&lt;0.05), TTG (0.49&gt;0.32) and HIVTB-G groups (0.49&gt;0.27, p-value&lt;0.05). Our data confirm a significant difference in monocyte to lymphocyte blood ratio in tuberculosis disease. These data may be useful for monitoring and revising implementation plans for the different phases of tuberculosis disease (latent Mycobacterium tuberculosis (MTB) infection versus TB active disease). Regarding HIV samples, the small sample size is somewhat offset by the need, fully satisfied in our sample, to enlist specific patients such as co-infected HIV/TBC who voluntarily submit to clinical trials in our geographical area

KPC-3 Klebsiella pneumoniae ST258 clone infection in postoperative abdominal surgery patients in an intensive care setting: analysis of a case series of 30 patients

Objective: We studied the clinical course, Intensive Care Unit (ICU) and hospital outcomes of 30 postoperative abdominal surgery patients who showed severe infections caused by Klebsiella pneumoniae Sequence Type 258 producing K. pneumoniae carbapenemase 3 (KPC-Kp). Methods: Patients with at least two positive blood cultures for KPC-Kp after admission to the ICU were recruited for a 12-month period and treated with a combination regimen of colistin plus tigecycline. They were started on a high-dose (initial dose of 200 mg then 100 q12) of tigecycline combined with colistin, taking into account intra-abdominal abscess severity and MCIs for tigecycline. Results: The average age of the patients was 56.6 ± 15 (male = 16, female = 14), average APACHE score on admission was 22.72. Twenty out of 30 patients (66%) came from the surgical emergency unit. Patients showed KPC-Kp postoperative infection as follows: intra-abdominal abscess in 15 patients (50%), anastomotic leakage in 8 (24%), surgical site infection (SSI) in 4 (12%) and peritonitis in 3 (10%). Overall crude mortality rate in the ICU due to infection was 40% (12 out of 30 patients). Twelve out of 30 patients (40%) were started on a combination treatment of high-dose tigecycline and intravenous colistin; five of them showed tigecycline MICs of 0.8 - 1. Mortality was significantly associated with a greater number of surgical procedures, previous ICU admission (<0.0005), APACHE II ( p=0.018)and SOFA score (p<0.0005) and VAP (0.013). Treatment with high doses of tigecycline obtained a favourable outcome in patients with intraabdominal abscess. Discussion: Critically-ill surgical patients with KPC-Kp infections have to be treated in a timely manner, taking into account the severity of post-operative complications such as intra-abdominal abscess and anastomotic leakage. In these cases, early suspicion and detection are essential to reducing infection-related morbidity and mortality. Finally, studies evaluating antibiotic combination therapy and well-controlled clinical trials are needed to define the optimal treatment of infections caused by KPC-Kp and, more generally, carbapenem-resistant bacteria

Positioning of darunavir/cobicistat-containing antiretroviral regimens in real life: Results from a large multicentre observational prospective cohort (SCOLTA)

Background: Study aim was to evaluate the safety and durability of darunavir/cobicistat (DRV/c) in a real life setting. Methods: Multicentre prospective cohort study performed in the context of SCOLTA (Surveillance Cohort Long-Term Toxicity Antiretrovirals). Patients were evaluated at baseline, week 24 and 48. Changes were evaluated using the paired t test or signed rank test. The multivariable analysis was performed using a general linear model, after ranking of not normally distributed variables. Results: A total of 249 patients were included, 72 (29%) were in DRV/c-based dual therapies (DT). Hypercholesterolemia, HC, (total cholesterol (TC) ≥ 200 mg/dL or low density-C (LDL-C) ≥ 130 or statin use) was present in 121 (48.6%) and hypertriglyceridemia, (triglycerides (TG) ≥ 200 mg/dl or fibrate use) in 41 (16.5%) patients. Blood lipid profile did not change significantly in either the global population or patients with HC. After a median observation of 17 months (IQR 13-20), 59 (25.3%) patients discontinued DRV/c, of which 13 were in DT. The durability DT resulted higher than that of triple therapy (log-rank test p = 0.01). Main reasons for stopping DRV/c were simplification (15 patients), adverse events (13 patients), planned discontinuation for treatment initiation with DAA (4 patients), treatment failure (2 patients); death (2 patients), other causes (10 patients). Twenty-six were lost to follow-up. Conclusions: DRV/c was safe and well tolerated. Dual therapies showed a better profile of tolerability and a longer durability compared to triple therapies

Use of colistin in adult patients: A cross-sectional study

Objectives: The aim of this study was to assess colistin use in a country endemic for multidrug-resistant Gram-negative bacteria (MDR-GNB). Methods: Colistin prescription patterns were evaluated in 22 Italian centres. Factors associated with use of colistin in combination with other anti-MDR-GNB agents were also assessed. Results: A total of 221 adults receiving colistin were included in the study. Their median age was 64 years (interquartile range 52\u201373 years) and 134 (61%) were male. Colistin was mostly administered intravenously (203/221; 92%) and mainly for targeted therapy (168/221; 76%). The most frequent indications for colistin therapy were bloodstream infection and lower respiratory tract infection. Intravenous colistin was administered in combination with at least another anti-MDR-GNB agent in 80% of cases (163/203). A loading dose of 9 MU of colistimethate was administered in 79% of patients receiving i.v. colistin and adequate maintenance doses in 85%. In multivariable analysis, empirical therapy [odds ratio (OR) = 3.25, 95% confidence interval (CI) 1.24\u20138.53;P = 0.017] and targeted therapy for carbapenem-resistant Enterobacterales infection (OR = 4.76, 95% CI 1.69\u201313.43; P = 0.003) were associated with use of colistin in combination with other agents, whilst chronic renal failure (OR = 0.39, 95% CI 0.17\u20130.88; P = 0.024) was associated with use of colistin monotherapy. Conclusion: Colistin remains an important option for severe MDR-GNB infections when other treatments are not available. Despite inherent difficulties in optimising its use owing to peculiar pharmacokinetic/pharmacodynamic characteristics, colistin was mostly used appropriately in a country endemic for MDR-GNB