Epidemiology of Coccidioidomycosis in Missouri

Introduction. Incidence of Coccidioidomycosis has been increasing nationally, from 2,271 cases in 1998 to 17,802 cases in 2012. Missouri is not endemic to Coccidioidomycosis but the incidence has been increasing since becoming reportable in 2003. To describe epidemiology of Coccidioidomycosis in Missouri we conducted a retrospective review of surveillance data at Missouri Department of Health & Senior Services (DHSS) for the years, 2004-2013. Methods. Data was obtained from Missouri Health Surveillance Information System (WebSurv), the statewide reporting system for notifiable diseases. All cases that were Confirmed were included in the study. Results. There were a total of 93 confirmed cases eligible for the study, of which 67 (72%) were male and 26 (28%) were female. The incidence rate of Coccidioidomycosis increased from 0.05 per 100,000 population in 2004 to 0.28 per 100,000 in 2013. The age groups, \u3e 70 yrs. (24%) and 60-69 years (23%) were most affected. The predominant race was white accounting for 54 % of cases and the race of 37 % was unknown. Pneumonia (23%) and Flu-like illness (22%) were the most common presentations. Culture (26%) and Complement Fixation (20%) were the most common diagnostic tests. Median time from symptom onset to diagnosis was 25 days (range 3 - 304 days). A total of 43 (46%) patients required hospitalization and 5 of these were admitted to an ICU. Of the 69 patients with known travel history, 45 had history of travel to endemic regions and 24 had no travel history. Mapping of cases with and without history of travel to the endemic areas outside the state revealed that cases were occurring in all regions of Missouri. Those with history of travel were significantly more likely to be diagnosed based on positive culture and/or PCR testing compared to those who did not travel, who were more likely to be diagnosed with serological tests. Conclusions. Our study demonstrated significant increase in the incidence of Coccidioidomycosis in Missouri during 2004-2013. Majority of cases were related to travel to endemic areas. There was a similar distribution of cases with or without travel to endemic areas across the state. Additional studies will be required to ascertain whether true endemic cases exist in Missouri

The effect of red blood cell transfusion on tissue oxygenation and microcirculation in severe septic patients

BACKGROUND: Microcirculation plays a vital role in the development of multiple organ failure in severe sepsis. The effects of red blood cell (RBC) transfusions on these tissue oxygenation and microcirculation variables in early severe sepsis are not well defined. METHODS: This is a prospective, observational study of patients with severe sepsis requiring RBC transfusions of one to two units of non-leukoreduced RBCs for a hemoglobin < 7.0, or for a hemoglobin between 7.0 and 9.0 with lactic acidosis or central venous oxygen saturation < 70%. This study took place in a 54-bed, medical-surgical intensive care unit of a university-affiliated hospital. Thenar tissue oxygen saturation was measured by using a tissue spectrometer on 21 patients, and a vaso-occlusive test was performed before and 1 hour after transfusion. The sublingual microcirculation was assessed with a Sidestream Dark Field device concomitantly on 11 of them. RESULTS: RBC transfusion resulted in increase in hemoglobin (7.23 (± 0.87) to 8.75 (± 1.06) g/dl; p < 0.001). RBC transfusion did not globally affect near-infrared spectrometry (NIRS)-derived variables. However, percent change in muscle oxygen consumption was negatively correlated with baseline (r = - 0.679, p = 0.001). There was no statistically significant correlation between percent change in vascular reactivity and baseline (p = 0.275). There was a positive correlation between percent change in oxygen consumption and percent change in vascular reactivity (r = 0.442, p = 0.045). In the 11 patients, RBC transfusion did not globally affect NIRS-derived variables or SDF-derived variables. There was no statistically significant correlation between percent change in small vessel perfusion and baseline perfusion (r = -0.474, p = 0.141), between percent change in small vessel flow and baseline flow (r = -0.418, p = 0.201), or between percent change in small vessel perfusion and percent change in small vessel flow (r = 0.435, p = 0.182). CONCLUSIONS: In a small sample population, muscle tissue oxygen consumption, microvascular reactivity and sublingual microcirculation were globally unaltered by RBC transfusion in severe septic patients. However, muscle oxygen consumption improved in patients with low baseline and deteriorated in patients with preserved baseline. Future research with larger samples is needed to further examine the association between RBC transfusion and outcomes of patients resuscitated early in severe sepsis, with an emphasis on elucidating the potential contribution of microvascular factors