Expanding the horizons of histoplasmosis: disseminated histoplasmosis in a renal transplant patient after a trip to Bangladesh

U. Rappo, J.R. Beitler, J.R. Faulhaber, B. Firoz, J.S. Henning, K.M. Thomas, M. Maslow, D.S. Goldfarb, H.W. Horowitz. Expanding the horizons of histoplasmosis: disseminated histoplasmosis in a renal transplant patient after a trip to Bangladesh.
Transpl Infect Dis 2010: 12: 155–160. All rights reserved Abstract: Histoplasmosis is recognized to occur in the Ohio and Mississippi River Valleys of the United States, but less widely appreciated is its worldwide distribution. We report a case of disseminated histoplasmosis with disease involving skin, lungs, and epiglottis in a renal transplant patient 6 months after a trip to Bangladesh, to highlight the potential risk of acquisition of this infection in the Indian subcontinent.     

Progressive disseminated histoplasmosis: a systematic review on the performance of non-culture-based diagnostic tests

The diagnosis of progressive disseminated histoplasmosis is often a challenge to clinicians, especially due to the low sensitivity and long turnaround time of the classic diagnostic methods. In recent years, studies involving a variety of non-culture-based diagnostic tests have been published in the literature. We performed a systematic review by selecting studies evaluating non-culture-based diagnostic methods for progressive disseminated histoplasmosis. We searched for articles evaluating detection of antibody, antigens, as well as DNA-based diagnostic methods. A comprehensive PUBMED, Web of Science, and Cochrane Library search was performed between the years 1956 and 2016. Case reports, review articles, non-human models and series involving less than 10 patients were excluded. We found 278 articles and after initial review 18 articles were included: (12) involved antigen detection methods, (4) molecular methods, and (2) antibody detection methods. Here we demonstrate that the pursuit of new technologies is ultimately required for the early and accurate diagnosis of disseminated histoplasmosis. In particular, urinary antigen detection was the most accurate tool when compared with other diagnostic techniques.     

Clinical and laboratory features of disseminated histoplasmosis in HIV patients from Brazil

OBJECTIVES: To identify the main clinical and laboratory features of disseminated histoplasmosis (DH) in human immunodeficiency virus (HIV) patients and compare them with those of HIV patients with other opportunistic diseases. METHODS: Retrospective study of HIV patients comparing the clinical and laboratory data of patients with and without DH. Univariate and multivariate analyses were performed to verify the risk factors related to DH. RESULTS: In total, 378 HIV patients were included, 164 with DH and 214 with other opportunistic diseases. Acute renal failure, respiratory insufficiency and septic shock were more frequent in DH patients, who also had a higher mortality (32%vs. 14%, P < 0.001). Independent risk factors for DH were: acute renal failure [odds ratio (OR) 5.2; 95% confidence interval (CI) 3.2-8.5; P < 0.001], splenomegaly (OR 3.4; 95% CI 1.19-9.9; P < 0.001), respiratory insufficiency (OR 2.7 95% CI 1.5-5.0; P < 0.001), proteinuria (OR 2.7; 95% CI 1.3-5.2; P = 0.03), hypotension (OR 2.5; 95% CI 1.2-5.0; P = 0.008), hepatomegaly (OR 2.4; 95% CI 1.2-4.8; P = 0.01), cutaneous lesions (OR, 1.9; 95% CI 1.0-3.3; P = 0.02) and weight loss (OR 1.8; 95% CI 1.0-3.1; P = 0.03). CONCLUSION: Our results suggest that DH is a severe opportunistic disease with high mortality rate, which should be promptly recognized in order to provide early specific treatment.     

Case report and review of disseminated histoplasmosis in South-East Asia: clinical and epidemiological implications

The South‐East Asian region is not known to be a major endemic area for histoplasmosis. We have recently diagnosed several cases of disseminated histoplasmosis in patients from this region. We report on a well documented indigenous case of disseminated histoplasmosis in a 62‐year‐old poultry farmer and review the literature for other reported cases of clinical histoplasmosis in the South‐East Asian region. Sporadic cases of indigenous chronic pulmonary and non‐meningeal disseminated histoplasmosis in immunocompetent hosts have been reported as well as examples of disseminated histoplasmosis in immunocompromised hosts. These reports suggest that histoplasmosis is endemic to certain areas in South‐East Asia and that there may be a large number of undiagnosed and subclinical cases. The recent advances in diagnostic tests for histoplasmosis are also reviewed with reference to the experience of using these tests in the reported case.     

A case of disseminated histoplasmosis following autologous stem cell transplantation for Hodgkin's lymphoma: an initial misdiagnosis with a false-positive serum galactomannan assay

Abstract: Systemic histoplasmosis is uncommonly reported in patients who have undergone bone marrow or solid organ transplantation. Diagnosis of systemic histoplasmosis in recipients of transplants may be hampered by lack of consideration of this infection in the differential diagnosis and may be confounded by conflicting information from other testing performed to evaluate for opportunistic infections in this population. We report successful treatment of a case of disseminated histoplasmosis in a patient with Hodgkin's lymphoma who had undergone autologous stem cell transplantation. The diagnosis was delayed by the finding of a positive serum galactomannan assay.     

Knowledge,attitudes, behaviors,and practices differences regarding HIV in populations living along the Maroni river: particularities of operational interest for Amerindian and Maroon populations

The Maroni basin, an isolated region delineating the border between Suriname and French Guiana has been affected by the human immunodeficiency virus (HIV) epidemic 10 years after coastal French Guiana. However, the rise in HIV prevalence was sharp, exceeding 1% within 10 years. The aim of the present study is to compare, using the first quantitative data from the general population in remote villages, the knowledge, attitudes, and behaviors regarding HIV between Maroon and Amerindian populations, the two most frequent populations living along the Maroni. Data were collected in 2012 using a structured questionnaire among a random sample of 896 individuals residing in the remote villages on the Maroni river. Proportions were compared between the Maroni and the coastal general population, and between Maroon and Amerindian populations. The present study shows significant differences between territories and between communities living on the Maroni river: the multiple sexual partnerships, more common among population living on the Maroni river, were more frequently reported in Maroons than in Amerindians. Condom use was more frequently reported among men on the Maroni river than on the coast, but these findings were reversed for women. Moreover, among people living on the Maroni river, condom use was more frequently reported among Maroons than among Amerindians. Regarding genital factors that may affect transmission, penile implant seemed to have no ethnic boundaries, steam baths seemed specific to Maroon women. The present results should help to improve community-based specific interventions.     

Increased Duration of Dual Pegylated Interferon and Ribavirin Therapy for Genotype 1 Hepatitis C Post-liver Transplantation Increases Sustained Virologic Response: A Retrospective Review

Background/Aim:

In patients with advanced post-transplant hepatitis C virus (HCV) recurrence, antiviral treatment (AVT) with interferon and ribavirin is indicated to prevent graft failure. The aim of this study was to determine and report Canadian data with respect to the safety, efficacy, and spontaneous virologic response (SVR) predictors of AVT among transplanted patients with HCV recurrence.

Patients and Methods:

A retrospective chart review was performed on patients transplanted in London, Ontario and Edmonton, Alberta from 2002 to 2012 who were treated for HCV. Demographic, medical, and treatment information was collected and analyzed.

Results:

A total of 85 patients with HCV received pegylated interferon with ribavirin post-liver transplantation and 28 of the 65 patients (43%) with genotype 1 achieved SVR. Of the patients having genotype 1 HCV who achieved SVR, there was a significantly lower stage of fibrosis (1.37 ± 0.88 vs. 1.89 ± 0.96; P = 0.03), increased ribavirin dose (total daily dose 1057 ± 230 vs. 856 ± 399 mg; P = 0.02), increased rapid virologic response (RVR) (6/27 vs. 0/31; P = 0.05), increased early virologic response (EVR) (28/28 vs. 18/35; P = 0.006), and longer duration of therapy (54.7 ± 13.4 weeks vs. 40.2 ± 18.7; P = 0.001). A logistic regression model using gender, age, RVR, EVR, anemia, duration of therapy, viral load, years’ post-transplant, and type of organ (donation after cardiac death vs. donation after brain death) significantly predicted SVR (P < 0.001), with duration of therapy having a significant odds ratio of 1.078 (P = 0.007).

Conclusions:

This study identified factors that predict SVR in HCV-positive patients who received dual therapy post-transplantation. Extending therapy from 48 weeks to 72 weeks of dual therapy is associated with increased SVR rates. Future studies examining the role of extended therapy are needed to confirm these findings, since the current study is a retrospective one.     

Asian diagnostic criteria for autoimmune pancreatitis: consensus of the Japan-Korea Symposium on Autoimmune Pancreatitis

In 2002, the Japan Pancreas Society (JPS) was the first in the world to propose diagnostic criteria for autoimmune pancreatitis (AIP). Since the concept of AIP has changed with the accumulation of AIP cases, the Research Committee of Intractable Pancreatic Diseases (RCIPD) provided by the Ministry of Health, Labour and Welfare of Japan and the JPS issued revised clinical diagnostic criteria of AIP in 2006. The Asan Medical Center of Korea also proposed diagnostic criteria for AIP in 2006. However, there are subtle but clinically challenging differences between the Japanese and Korean criteria. This inconsistency makes it difficult to compare data in studies from different centers and elucidate the characteristics of AIP. To reach a consensus on AIP, the RCIPD and the Korean Society of Pancreatobiliary Diseases established the following Asian criteria for the diagnosis of AIP: I-1. Imaging studies of pancreatic parenchyma show a diffuse/segmental/focally enlarged gland, occasionally with a mass and/or a hypoattenuation rim. I-2. Imaging studies of pancreaticobiliary ducts show diffuse/segmental/focal pancreatic ductal narrowing, often with stenosis of the bile duct. (Both I-1 and I-2 are required for diagnosis). II. Elevated level of serum IgG or IgG4, and detection of autoantibodies. III. Common lymphoplasmacytic infiltration and fibrosis, with abundant IgG4-positive cell infiltration. AIP should be diagnosed when criterion I and one of the other two criteria are satisfied, or when histology shows the presence of lymphoplasmacytic sclerosing pancreatitis in the resected pancreas. A diagnostic trial of steroid therapy can be applied carefully by expert pancreatologists only in patients fulfilling criterion I alone with negative diagnostic work-up results for pancreatobiliary cancer.     

Prevalence and prognostic significance of ECG abnormalities in HIV-infected patients: results from the Strategies for Management of Antiretroviral Therapy study

Background

It remains debated whether to include resting electrocardiogram (ECG) in the routine care of human immunodeficiency virus (HIV)–infected patients.

Methods

This analysis included 4518 HIV-infected patients (28% women and 29% blacks) from the Strategies for Management of Antiretroviral Therapy study, a clinical trial aimed to compare 2 HIV treatment strategies. ECG abnormalities were classified using the Minnesota Code. Cox proportional hazards analysis was used to examine the association between baseline ECG abnormalities and incident cardiovascular disease (CVD).

Results

More than half of the participants (n = 2325, or 51.5%) had either minor or major ECG abnormalities. Minor ECG abnormalities (48.6%) were more common than major ECG abnormalities (7.7%). During a median follow-up of 28.7 months, 155 participants (3.4%) developed incident CVD. After adjusting for the study-treatment arms, the presence of major, minor, and either minor or major ECG abnormalities was significantly predictive of incident CVD (hazard ratio [95% confidence interval]: 2.76 [1.74-4.39], P < .001; 1.58 [1.14-2.20], P = .006; 1.57 [1.14-2.18], P = .006, respectively). However, after adjusting for demographics, CVD risk factors, and HIV characteristics (full model), presence of major ECG abnormalities were still significantly predictive of CVD (1.83 [1.12-2.97], P = .015) but not minor or major abnormalities taken together (1.26 [0.89-1.79], P = .18; 1.25 [0.89-1.76], P = .20, respectively). Individual ECG abnormalities that significantly predicted CVD in the fully adjusted model included major isolated ST-T abnormalities, major prolongation of QT interval, minor isolated ST-T, and minor isolated Q-QS abnormalities.

Conclusion

Nearly 1 in 2 of the HIV-infected patients in our study had ECG abnormalities; 1 in 13 had major ECG abnormalities. Presence of ECG abnormalities, especially major ECG abnormalities, was independently predictive of incident CVD. These results suggest that the ECG could provide a convenient risk-screening tool in HIV-infected patients.     

Comparison of diagnostic criteria for disseminated intravascular coagulation (DIC): diagnostic criteria of the International Society of Thrombosis and Hemostasis and of the Japanese Ministry of Health and Welfare for overt DIC

We compared the criteria set by the International Society of Thrombosis and Hemostasis (ISTH) for the diagnosis of disseminated intravascular coagulation (DIC) with the criteria of the Japanese Ministry of Health and Welfare (JMHW) set for the diagnosis of overt DIC. We studied 1,284 Japanese patients with DIC. The rate of agreement in the diagnosis of DIC by the two diagnostic systems was 67.4%. In addition, only 2.0% of non-DIC patients by JMHW criteria were diagnosed with overt DIC by ISTH criteria, suggesting that ISTH for overt DIC includes typical cases of DIC. The concordance of diagnosis for DIC by ISTH and JMHW was significantly high in patients with trauma or acute promyelocytic leukemia. About 70% of DIC or overt DIC patients had more than 1 point in the scoring system for prothrombin time, but >50% of those patients had 0 point for plasma fibrinogen level. Abnormal fibrin and fibrinogen degradation product (FDP) levels and platelet counts were observed in >88% of DIC and overt DIC patients but were observed in >50% of non-DIC patients, indicating that these parameters are sensitive markers but not specific markers for the diagnosis of DIC. Considered together, our results suggest that the diagnostic criteria for DIC and overt DIC could be improved by changing the cut-off values of the global coagulation tests.     

The value of different imaging methods in the diagnosis of breast cancer: A protocol for network meta-analysis of diagnostic test accuracy

Background: Breast cancer (BC) is the most common cancer in women all over the world and the second most common cause of cancer-related mortality. Imaging examination plays an important role in the diagnosis of early breast cancer. Due to different imaging principles and methods, all kinds of examinations have their advantages and disadvantages. It is particularly important for clinicians to choose these examination methods reasonably to achieve the best diagnostic effect. The objectives of this systematic review and NMA are to determine the diagnostic accuracy of imaging technologies for breast cancer and to compare the diagnostic accuracy of different index tests and to support guidelines development and clinical practice.Methods: PubMed, Embase.com, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang, and SinoMed will be searched to identify relevant studies up to August 31, 2021. We will include random controlled trials, cross-sectional studies, case-control studies, and cohort studies that evaluate the diagnostic accuracy of different imaging diagnostic methods for breast cancer. The Quality Assessment of Diagnostic Accuracy Studies 2 quality assessment tool will be used to assess the risk of bias in each study. Standard pairwise meta-analysis and NMA will be performed using STATA V.12.0, MetaDiSc 1.40, and R 3.4.1 software to compare the diagnostic efficacy of different imaging diagnostic methods. Subgroup analyses and sensitivity analyses will be conducted to investigate the sources of heterogeneity.Results: The results of this study will be published in a peer-reviewed journal.Conclusion: This study will comprehensively evaluate the accuracy of different imaging diagnostic methods in the diagnosis of breast cancer. The results of this study will provide high-quality evidence to support clinical practice and guidelines development.     

Designing a sexual network study of men who have sex with other men: exploring racial and ethnic preferences in study design and methods

Black and Latino gay, bisexual, and other men who have sex with men (MSM) have higher rates of HIV and other sexually transmitted infections (STIs) than their White counterparts. Differences in sexual networks have been hypothesized to play an important role in the observed racial/ethnic disparities in risk. However, concerns about the acceptability and feasibility of conducting sociocentric sexual network studies have left a dearth of data on the structure of sexual networks of MSM. If certain network research procedures are unacceptable among target populations, biases may be introduced. We conducted qualitative interviews and brief surveys with 30 self-identified Black (n?=?12), Hispanic/Latino, (n?=?9) and White (n?=?9) sexually active MSM in the Greater Boston area to assess the acceptability and feasibility of potential procedures for a sociocentric sexual network study. We found that referring recent sexual partners as part of a sociocentric network study was generally acceptable, but racial/ethnic differences emerged regarding specific preferences for how to recruit sexual partners. While the majority of Black participants (7/12) explained that they would not want their name disclosed to sexual partners approached for study participation, most Latino participants (7/9) preferred having the opportunity to inform referrals themselves about the study prior to researchers contacting them, and White participants (8/9) favored having researchers disclose their names when recruiting referrals, emphasizing the importance of transparency. In order to reduce differential rates of research participation, increase scientific validity, and reduce risks of social harm, researchers studying sexual networks among MSM should be aware of these potential differences, engage communities in study design, and provide participants with a variety of options for recruiting their sexual partners.     

Sometimes higher heart rate variability is not better heart rate variability: results of graphical and nonlinear analyses

OBJECTIVE: To determine the prevalence and effect on traditional heart rate variability (HRV) indices of abnormal HRV patterns in the elderly. METHODS: Hourly Poincaré plots and plots of spectral HRV from normal-to-normal interbeat intervals and hourly nonlinear HRV values were examined in a subset of 290 consecutive participants in the Cardiovascular Health Study. Only subjects in normal sinus rhythm with > or = 18 hours of usable data were included. Eligible subjects were 71 +/- 5 years. During 7 years of follow-up, 21.7% had died. Hours were scored as normal (0), borderline (0.5), or abnormal (1) from a combination of plot appearance and HRV. Summed scores were normalized to 100% to create an abnormality score (ABN). Short-term HRV versus each 5th percentile of ABN was plotted and a cutpoint for markedly increased HRV identified. The t-tests compared HRV for subjects above and below this cutpoint. Cox regression evaluated the association of ABN and mortality. RESULTS: Of 5,815 eligible hourly plots, 64.4% were normal, 14.5% borderline, and 21.1% abnormal. HR, SDNN, SDNNIDX, ln VLF and LF power, and power law slope did not differ by the cutpoint for increased short-term HRV, while SDANN and ln ULF power were significantly lower for those above the cutpoint. However, many HRV indices including LF/HF ratio and normalized LF and HF power were significantly different between groups (P < 0.001). Increased ABN was significantly associated with mortality (P = 0.019). Despite similar values for many HRV indices, being in the group above the cutpoint was significantly associated with mortality (P = 0.04). CONCLUSIONS: Abnormal HR patterns that elevate many HRV indices are prevalent among the elderly and associated with higher risk of mortality. Consideration of abnormal HRV may improve HRV-based risk stratification.     

Development and initial testing of Asthma Predictive Index for a retrospective study: an exploratory study

Objective: Asthma Predictive Index (API) has been used for predicting asthma in prospective or cross-sectional studies, not for a retrospective study. We aim to develop and validate API for a retrospective study. Methods: This is a cross-sectional study based on a convenience sample of children who participated in a previous retrospective cohort study. API was operationalized by two or more wheezing episodes in a year during the first 3 years of life PLUS one of the major or two of the minor criteria of the original API. We assessed validity of retrospective API against Predetermined Asthma Criteria (PAC) which has been extensively used in clinical studies for asthma. We assessed criterion validity by measuring kappa and agreement rate between API and PAC and construct validity by determining associations of API with known risk factors for asthma. Results: Of the eligible 105 children, 55 (52.4%) were male, 90 (85.7%) Caucasians, and the mean age (±SD) was 5.8 years (±1.5). API criteria was met by 15 (14.3%), compared to 33 (31.4%) by PAC, respectively. The agreement rate and kappa between API and definite asthma of PAC were 89.5% and 0.66 (p?<?0.01). Atopic conditions, lower parental education, no history of breastfeeding and family history of asthma were significantly associated with risk of asthma by API. Conclusions: Application of API to a retrospective study for ascertaining asthma status is suitable. Our study findings need to be replicated by future studies with a larger sample size.     

Single cuff comparison of two methods for indirect measurement of arterial blood pressure: standard auscultatory method versus automatic oscillometric method

Summary With the introduction of automatic oscillometric systems for indirect measurement of arterial blood pressure (e. g. DINAMAP), the problem of correspondence between that method and the standard auscultatory method arose. For an exact and valid comparison of two methods, for physiological and methodological reason, both measurements have to be performed simultaneously and using only one single cuff.Applying a methodological approach fulfilling these preconditions and offering in addition the advantage of a graphic documentation of the individual measurement cycles, we were able to investigate both methods in a sample of 216 comparative experiments.We found a mean difference (auscultatory method minus oscillometric method) between the methods (bias) of –0.82 mm Hg (–0.109 kPa) for systolic pressure, 1.25 mm Hg (0.166 kPa) for diastolic pressure and 1.00 mm Hg (0.133 kPa) for mean pressure. Except for systolic pressure, the differences were statistically significant (paired t-test and analysis of variance). We also obtained a significant negative correlation between the differences and the average of both pressure values (decreasing error with increasing pressure) and a significant negative correlation between differences and heart rate (decreasing differences with increasing heart rate).The conclusions drawn from the comparative study are that, although the oscillometric method exhibited a tendency to higher systolic and lower diastolic measurement values compared to the auscultatory method, both methods are well comparable and the differences are below the level of physiological and clinical significance.     

地方性氟中毒临床与X线表现及两种方法诊断分度结果比较

目的进一步了解地方性氟中毒临床与X线表现、特点及2种方法诊断氟中毒结果的差异,为临床诊断提供参考。方法(1)对112名高氟区居民进行临床症状询问和体征检查,统计各种症状、体征检出率,依据其表现进行临床诊断与分度。(2)拍摄全身骨和关节X线照片,统计各部位阳性征象检出率,按照现行标准进行X线诊断与分度,(3)比较临床与X线2种方法诊断、分度结果及差别。结果地方性氟中毒的临床表现分为(1)一般中毒症状如头痛、头迷,肢体抽麻和消化道症状;(2)骨关节疼痛症状如腰、膝、髋、肘、肩、颈等大关节持续性休息痛;(3)骨关节运动功能障碍体征,包括颈部、上肢、下肢和脊柱。在全身骨关节X线照片中,骨盆、前臂、小腿阳性征象检出率最高。临床和X线方法检出率分别为85.7%和83.0%,2种方法诊断结果的差别无显著性(P>0.05)。但是,2种方法在轻度和中度的判定上的差别有显著性(P<0.01)。临床分度与X线分度的符合率为41.96%。结论地方性氟中毒主要表现为一般中毒症状,多关节持续性休息痛和肢体运动功能障碍。骨盆、前臂、小腿是氟中毒X线阳性征象的易感部位。尽管临床与X线2种方法在其严重程度的判定上有交叉性,但总的诊断结果一致。     

Addition of non-pharmacological methods of treatment in patients on antihypertensive drugs: results of previous medication, laboratory tests and life quality

Four hundred patients from eight health centres were recruited for this 2-year study on the possible replacement of antihypertensive drugs by non-pharmacological therapy. All the patients were given a device to measure their blood pressure at home and had monthly checks at a health centre. Two hundred patients on antihypertensive drugs (G1) started additional non-pharmacological therapy after 1 year in the study, while the rest (G2) had used it from the beginning. Antihypertensive drugs were withdrawn according to predetermined criteria. The drop-out rate was 1.5% each year. Medication was withdrawn completely from 42.7% of G1, and in 21.5% it was withheld for at least 18 months. The corresponding figures for G2 were 46.4% and 25.5% respectively. Most of the medication withdrawal in G1 occurred during the first year, when the group's management consisted solely of blood pressure measurements at home and frequent visits to the health centre. Serum triglycerides decreased on non-pharmacological treatment in both sexes in both groups. Life quality improved, particularly for the group (n = 173) that had the drugs withdrawn.