469 research outputs found
One-year mortality of HIV-positive patients treated for rifampicin- and isoniazid- susceptible tuberculosis in Eastern Europe, Western Europe and Latin America
OBJECTIVES: The high mortality among HIV/tuberculosis (TB) coinfected patients in Eastern Europe is partly explained by the high prevalence of drug-resistant TB. It remains unclear whether outcomes of HIV/TB patients with rifampicin/isoniazid-susceptible TB in Eastern Europe differ from those in Western Europe or Latin America. METHODS: One-year mortality of HIV-positive patients with rifampicin/isoniazid-susceptible TB in Eastern Europe, Western Europe, and Latin America was analysed and compared in a prospective observational cohort study. Factors associated with death were analysed using Cox regression modelsRESULTS:: Three hundred and forty-one patients were included (Eastern Europe 127, Western Europe 165, Latin America 49). Proportions of patients with disseminated TB (50, 58, 59%) and initiating rifampicin + isoniazid + pyrazinamide-based treatment (93, 94, 94%) were similar in Eastern Europe, Western Europe, and Latin America respectively, whereas receipt of antiretroviral therapy at baseline and after 12 months was lower in Eastern Europe (17, 39, 39%, and 69, 94, 89%). The 1-year probability of death was 16% (95% confidence interval 11-24%) in Eastern Europe, vs. 4% (2-9%) in Western Europe and 9% (3-21%) in Latin America; P < 0.0001. After adjustment for IDU, CD4 cell count and receipt of antiretroviral therapy, those residing in Eastern Europe were at nearly 3-fold increased risk of death compared with those in Western Europe/Latin America (aHR 2.79 (1.15-6.76); P = 0.023). CONCLUSIONS: Despite comparable use of recommended anti-TB treatment, mortality of patients with rifampicin/isoniazid-susceptible TB remained higher in Eastern Europe when compared with Western Europe/Latin America. The high mortality in Eastern Europe was only partially explained by IDU, use of ART and CD4 cell count. These results call for improvement of care for TB/HIV patients in Eastern Europe
Enterococcus faecalis bacteremia: please do the echo
Infective endocarditis (IE) caused by Enterococcus faecalis (E. faecalis) is a disease of the elderly with an increasing incidence, often health-care associated and with in-hospital mortality rates around 10-20%. E. faecalis IE is notoriously challenging to diagnose due to unspecific symptoms, often presenting with a complex clinical picture with low-grade fever and only moderately elevated infectious parameters. In a newly published prospective multicenter study using echocardiography to screen E. faecalis bacteremia patients, we found an IE prevalence as high as 26%. The 344 included patients with E. faecalis bacteremia had a mean age of 74 (±12) years confirming that it is indeed a disease of the elderly. The key feature of the study was that echocardiography was performed in all patients including transesophageal echocardiography (TEE) in 74%. Transthoracic echocardiography (TTE) missed vegetations in half of the cases where TEE demonstrated vegetations, underlining the importance of TEE
Baseline genotype testing to assess drug resistance before beginning HIV treatment
To the Edito
Comparative effectiveness of immediate antiretroviral therapy versus CD4-based initiation in HIV-positive individuals in high-income countries:observational cohort study
Background Recommendations have differed nationally and internationally with respect to the best time to start antiretroviral therapy (ART). We compared effectiveness of three strategies for initiation of ART in high-income countries for HIV-positive individuals who do not have AIDS: immediate initiation, initiation at a CD4 count less than 500 cells per mu L, and initiation at a CD4 count less than 350 cells per mu L. Methods We used data from the HIV-CAUSAL Collaboration of cohort studies in Europe and the USA. We included 55 826 individuals aged 18 years or older who were diagnosed with HIV-1 infection between January, 2000, and September, 2013, had not started ART, did not have AIDS, and had CD4 count and HIV-RNA viral load measurements within 6 months of HIV diagnosis. We estimated relative risks of death and of death or AIDS-defining illness, mean survival time, the proportion of individuals in need of ART, and the proportion of individuals with HIV-RNA viral load less than 50 copies per mL, as would have been recorded under each ART initiation strategy after 7 years of HIV diagnosis. We used the parametric g-formula to adjust for baseline and time-varying confounders. Findings Median CD4 count at diagnosis of HIV infection was 376 cells per mu L (IQR 222-551). Compared with immediate initiation, the estimated relative risk of death was 1.02 (95% CI 1.01-1.02) when ART was started at a CD4 count less than 500 cells per mu L, and 1.06 (1.04-1.08) with initiation at a CD4 count less than 350 cells per mu L. Corresponding estimates for death or AIDS-defining illness were 1.06 (1.06-1.07) and 1.20 (1.17-1.23), respectively. Compared with immediate initiation, the mean survival time at 7 years with a strategy of initiation at a CD4 count less than 500 cells per mu L was 2 days shorter (95% CI 1-2) and at a CD4 count less than 350 cells per mu L was 5 days shorter (4-6). 7 years after diagnosis of HIV, 100%, 98.7% (95% CI 98.6-98.7), and 92.6% (92.2-92.9) of individuals would have been in need of ART with immediate initiation, initiation at a CD4 count less than 500 cells per mu L, and initiation at a CD4 count less than 350 cells per mu L, respectively. Corresponding proportions of individuals with HIV-RNA viral load less than 50 copies per mL at 7 years were 87.3% (87.3-88.6), 87.4% (87.4-88.6), and 83.8% (83.6-84.9). Interpretation The benefits of immediate initiation of ART, such as prolonged survival and AIDS-free survival and increased virological suppression, were small in this high-income setting with relatively low CD4 count at HIV diagnosis. The estimated beneficial effect on AIDS is less than in recently reported randomised trials. Increasing rates of HIV testing might be as important as a policy of early initiation of ART
Patients at Risk of Complications of Staphylococcus aureus Bloodstream Infection
Staphylococcus aureus is one of the most common causative pathogens of bloodstream infections (BSIs). In approximately one-half of patients with S. aureus BSI, no portal of entry can be documented. This group of patients has a high risk of developing septic metastases. Similarly, patient populations at high risk of S. aureus BSI and BSI-associated complications include patients receiving hemodialysis, injection drug users, patients with diabetes, and patients with preexisting cardiac conditions or other comorbidities. One of the most severe complications of S. aureus BSI is infective endocarditis, and S. aureus is now the most common cause of infective endocarditis in the developed world. Patients with methicillin-resistant S. aureus BSI or infective endocarditis have higher rates of mortality, compared with patients with methicillin-susceptible S. aureus infection. Nasal carriage is the most important source of S. aureus BSI. Better eradication and control strategies, including nasal decolonization and more-active antibiotics, are needed to combat S. aureus BSI
Predictors of the perceived risk of COVID-19 and adherence to confinement guidelines in the context of the COVID-19 pandemic
INTRODUCTION: Complete adherence to public health guidelines is essential to reduce the spread of COVID-19. Studies on the factors associated with increased/decreased adherence to these measures have the potential to inform public policies directed at increasing adherence, and thus helping to control the spread of the current pandemic. OBJECTIVES: This study aimed at assessing the demographic and psychosocial predictors of the perceived risk of the COVID-19 and adherence to confinement guidelines during the first mandatory lockdown in Portugal. METHODS: A convenience sample of 430 adults living in Portugal between March 19(th)Â and May 2(nd,)Â 2020 completed an online survey asking participants about the perceived risk of the COVID-19 and adherence to confinement guidelines. Participants also completed a sociodemographic questionnaire and measures of psychological function. Multiple regression analysis was performed. RESULTS: Teleworking and Risk and COVID-19 controllability were significant predictors of the perceived risk of COVID-19 as measured by the perceived risk of being infected with COVID-19. Teleworking participants and those perceiving COVID-19 as less controllable reported a higher perceived risk of being infected with COVID-19 than those who were not in telework and perceived COVID-19 as a controllable condition. Adherence to confinement guidelines was predicted by the mental health status and perceived risk of COVID-19. Participants who reported worse mental health status, who perceived COVID-19 as a dangerous condition, and who trusted the public health system reported greater adherence to confinement guidelines. CONCLUSIONS: The results of this study will be discussed considering their implications to public health policymaking to promote adherence to public health policies. DISCLOSURE: No significant relationships
Regional differences in AIDS and non-AIDS related mortality in HIV-positive individuals across Europe and Argentina: the EuroSIDA study
BACKGROUND
Differences in access to care and treatment have been reported in Eastern Europe, a region with one of the fastest growing HIV epidemics, compared to the rest of Europe. This analysis aimed to establish whether there are regional differences in the mortality rate of HIV-positive individuals across Europe, and Argentina.
METHODS
13,310 individuals under follow-up were included in the analysis. Poisson regression investigated factors associated with the risk of death.
FINDINGS
During 82,212 person years of follow-up (PYFU) 1,147 individuals died (mortality rate 14.0 per 1,000 PYFU (95% confidence interval [CI] 13.1-14.8). Significant differences between regions were seen in the rate of all-cause, AIDS and non-AIDS related mortality (global p<0.0001 for all three endpoints). Compared to South Europe, after adjusting for baseline demographics, laboratory measurements and treatment, a higher rate of AIDS related mortality was observed in East Europe (IRR 2.90, 95%CI 1.97-4.28, p<.0001), and a higher rate of non-AIDS related mortality in North Europe (IRR 1.51, 95%CI 1.24-1.82, p<.0001). The differences observed in North Europe decreased over calendar-time, in 2009-2011, the higher rate of non-AIDS related mortality was no longer significantly different to South Europe (IRR 1.07, 95%CI 0.66-1.75, p = 0.77). However, in 2009-2011, there remained a higher rate of AIDS-related mortality (IRR 2.41, 95%CI 1.11-5.25, p = 0.02) in East Europe compared to South Europe in adjusted analysis.
INTERPRETATIONS
There are significant differences in the rate of all-cause mortality among HIV-positive individuals across different regions of Europe and Argentina. Individuals in Eastern Europe had an increased risk of mortality from AIDS related causes and individuals in North Europe had the highest rate of non-AIDS related mortality. These findings are important for understanding and reviewing HIV treatment strategies and policies across the European region
Infeccions bacterianes i fungiques en adictes a drogues per via parenteral
L'addicció a drogues per via parenteral i les seves complicacions mèdiques constitueixen en el nostre paÃs un problema real i greu. Avui dia no sorprén a ningú que els mitjans de difusio social i les revistes mèdiques nacionals es facin ressó, quasi cada dia, d'algun deis múltiples problemes relacionats amb la drogaaddicció, com poden ser la mort d'heroÃnomans per sobredosi o la descripció de complicacions infeccioses greus. Hi han alguns hospitals urbans els addictes a drogues per via parenteral (ADVP) representen un percentatge important del total de consultes en els Serveis d'Urgències i del total d'ingresos, sobretot en determinades Àrees Mèdiques com Unitats de Cures Intensives o Serveis d'Infeccions. El motiu de la consulta van des de la recerca d'un tractament per a la seva dependència fÃsica o psÃquica fins a l'aparició de complicacions infeccioses greus o Taturada cardio-respiratòria per sobredosi. Quasi sense haver-nos-en adonat ens trobem davant d'una vertadera 'epidèmia', de gran magnitud i que tendeix a augmentar, les conseqüéncies socials i sanità ries de la qual son difÃcils de preveure
Colorectal Adenomas
Carta a l'editor com a resposta al document: https://doi.org/10.1056/NEJMra1513581In his review article, Strum (March 17 issue)1 provides data on the overall prevalence of colorectal adenomas in the United States and risk factors for these lesions. It is well established that patients with Streptococcus bovis–group infective endocarditis are at high risk for colorectal cancer.2 Although a strong relationship between Enterococcus faecalis endocarditis and colorectal adenomas is suspected, robust data are lacking
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