Coexistencia de artritis séptica y microcristalina: un reto diagnóstico. A propósito de 25 casos

ObjectiveSeptic arthritis is a medical emergency and crystal-induced arthritis is a risk factor for its development. If both occur simultaneously, crystal-induced arthritis may mask the diagnosis of infection and delay antibiotic therapy.MethodRetrospective analysis of patients with coexistence of septic and crystal-induced arthritis. We included only patients with isolation of crystals in synovial fluid analysis and positive culture of synovial fluid and/or blood culture.ResultsA total of 25 patients (17 men and 8 women) with a mean age of 67 years. The most commonly affected joint was the knee. In synovial fluid cytological studies, the most frequently identified crystals were monosodium urate. Risk factors included diabetes and chronic renal failure. The most frequently isolated germs were methicillin-sensitive S. aureus (48%), methicillin-resistant S. aureus (12%) and Mycobacterium tuberculosis (12%). In all, 36% of subjects required surgical drainage (excluding those caused by M. tuberculosis). Clinical outcome was favorable in 56%, although intercurrent complications were usual (40%). Mortality was 8%.ConclusionsCoexistence of septic and crystal-induced arthritis represents a diagnostic challenge and requires a high index of suspicion. Gout was the most prevalent crystal-induced arthritis. S. aureus was the most commonly causative pathogen, with a high rate of methicillin-resistant S. aureus infection. If treated early, the outcome is usually favorable, making synovial fluid microbiological study imperative.     

Nocardiosis pulmonar en pacientes con EPOC: características y factores pronósticos

Introduction

Pulmonary nocardiosis (PN) is a severe infection with a high morbidity and mortality that mainly affects immunocompromised patients. In recent years, an increase in PN cases has been detected among patients with chronic obstructive pulmonary disease (COPD). The factors that are associated with its presence and determine its prognosis remain unknown.

Methods

Retrospective study of COPD patients diagnosed with PN over the period from 1997-2009 at the Hospital de la Santa Creu i Sant Pau, in Barcelona (Spain). Demographic, clinical, microbiological and evolution data were evaluated in all cases

Results

Thirty patients were identified with PN and COPD. Mean age (standard deviation) was 76 (7) years and the mean FEV₁ was 40 (14)%. Chronic respiratory failure was observed in 56,7% patients and 51,7% had received systemic corticosteroid therapy previous to the PN diagnosis. The most common symptoms were cough and dyspnea (90%). Alveolar infiltrates were observed in 60% of the cases. The most frequently isolated Nocardia species was N. cyriacigeorgica (68%). The one-month mortality rate was 17%, while the one-year mortality rate was 33%. The factors associated with mortality within the first year included previous systemic corticosteroid treatment, less than three months of specific antibiotic therapy and active associated neoplasm.

Conclusions

PN affects patients with moderate-severe COPD and has high short- and mid-term mortality rates. Previous corticosteroid treatment, specific antibiotic therapy for less than 3 months and active neoplasia were factors associated with mortality.     

Human papillomavirus distribution in invasive cervical carcinoma in sub‐Saharan Africa: could HIV explain the differences?

Objectives To describe human papillomavirus (HPV) distribution in invasive cervical carcinoma (ICC) from Mali and Senegal and to compare type‐specific relative contribution among sub‐Saharan African (SSA) countries. Methods A multicentric study was conducted to collect paraffin‐embedded blocks of ICC. Polymerase chain reaction, DNA enzyme immunoassay and line probe assay were performed for HPV detection and genotyping. Data from SSA (Mozambique, Nigeria and Uganda) and 35 other countries were compared. Results One hundred and sixty‐four ICC cases from Mali and Senegal were tested from which 138 were positive (adjusted prevalence = 86.8%; 95% CI = 79.7–91.7%). HPV16 and HPV18 accounted for 57.2% of infections and HPV45 for 16.7%. In SSA countries, HPV16 was less frequent than in the rest of the world (49.4%vs. 62.6%; P < 0.0001) but HPV18 and HPV45 were two times more frequent (19.3%vs. 9.4%; P < 0.0001 and 10.3%vs. 5.6%; P < 0.0001, respectively). There was an ecological correlation between HIV prevalence and the increase of HPV18 and the decrease of HPV45 in ICC in SSA (P = 0.037 for both). Conclusion HPV16/18/45 accounted for two‐thirds of the HPV types found in invasive cervical cancer in Mali and Senegal. Our results suggest that HIV may play a role in the underlying HPV18 and HPV45 contribution to cervical cancer, but further studies are needed to confirm this correlation.     

Ethnic Density and Depressive Symptoms Among African Americans: Threshold and Differential Effects Across Social and Demographic Subgroups

Objectives. We examined the association between Black ethnic density and depressive symptoms among African Americans. We sought to ascertain whether a threshold exists in the association between Black ethnic density and an important mental health outcome, and to identify differential effects of this association across social, economic, and demographic subpopulations.Methods. We analyzed the African American sample (n = 3570) from the National Survey of American Life, which we geocoded to the 2000 US Census. We determined the threshold with a multivariable regression spline model. We examined differential effects of ethnic density with random-effects multilevel linear regressions stratified by sociodemographic characteristics.Results. The protective association between Black ethnic density and depressive symptoms changed direction, becoming a detrimental effect, when ethnic density reached 85%. Black ethnic density was protective for lower socioeconomic positions and detrimental for the better-off categories. The masking effects of area deprivation were stronger in the highest levels of Black ethnic density.Conclusions. Addressing racism, racial discrimination, economic deprivation, and poor services—the main drivers differentiating ethnic density from residential segregation—will help to ensure that the racial/ethnic composition of a neighborhood is not a risk factor for poor mental health.Recent years have seen an increase in the number of studies examining the association between the residential concentration of racial/ethnic minorities (ethnic density) and health, with increasingly sophisticated statistical techniques and theoretical frameworks helping to identify the relevance of ethnic density effects. Despite these improvements, the association between ethnic density and health, given the concentration of poverty in areas of higher ethnic density, is still a puzzling phenomenon.The literature is characterized by inconclusive findings in both the direction and the size of ethnic density effects. Reviews have asserted that ethnic density effects are stronger for mental health1 than for physical health, mortality, and health behaviors,2 but even among the latter set of outcomes, protective ethnic density effects are more common than adverse associations.2 One common finding among ethnic density studies, regardless of health outcome, is the variation in results across and within racial/ethnic groups. For example, US studies often report protective associations among Latinos but mostly detrimental associations for African Americans,2 and the few studies that have examined subgroups among broad “US Black” ethnic categories have found differences by age,3 gender,4,5 and nativity.6,7 Determining the specific populations for which ethnic density effects are protective or detrimental can help in achieving a greater understanding of the potential mechanisms by which ethnic density is associated with health.Another methodological improvement that would clarify the association between ethnic density and health is adequate adjustment for area resource deprivation. The positive correlation that exists between ethnic density and deprivation, and the established association between area deprivation and poor health,8 may have a twofold effect in concealing ethnic density effects: first, by overriding protective effects of ethnic density; second, by complicating analytical attempts at disentangling harmful deprivation effects from protective ethnic density benefits, even with the use of multilevel methods. Reviews of the literature have highlighted the inadequate adjustment for area deprivation as one of the main limitations in current studies, most of which control for only 1 measure of area deprivation (e.g., median income) or, in some cases, do not adjust for any relevant confounders.1,2Although the appropriate adjustment for area deprivation is critical for detecting ethnic density effects, it is not sufficient. To properly capture the associations between ethnic density, area resource deprivation, and health, the potential suppressing effects of area deprivation in the association between ethnic density and health should be modeled. Detrimental ethnic density effects may not be due to the concentration of ethnic minorities in an area but to the concurrent concentration of poverty and social adversity,9 and appropriate modeling can portray the relative contribution of ethnic density and area deprivation to health.In addition to differentiating ethnic density effects between subgroups and accurately modeling and adjusting for area deprivation, the possible nonlinearity in the association between ethnic density and health, and the potential thresholds at which ethnic density exerts protective or nonprotective effects on health, need to be addressed.10 The combination of methods and theoretical frameworks aiming to understand the importance of concentrated poverty and threshold effects for ethnic density might also be useful in clarifying the difference between ethnic density and residential segregation. Although ethnic density is framed in terms of social support, racial/ethnic diversity, and a stronger sense of community, residential segregation is a direct consequence of current and historical racism and discrimination, and is recognized as a determinant of racial/ethnic health inequalities.11 However, both ethnic density and residential segregation are conceptualized through use of a measure of racial/ethnic residential concentration, and it is unclear at what point the hypothesized protective benefits of ethnic density are overcome by the pernicious effects of racial residential segregation. Understanding this difference and its drivers has important implications for social and public health policy, as it would allow the promotion of factors that harness the protective effects of ethnic density while targeting the factors related to racial residential segregation.We examined the association between Black ethnic density and depressive symptoms among African Americans in the National Survey of American Life (NSAL), to ascertain (1) the differential effects of ethnic density across subgroups of African American NSAL respondents and (2) the protective or detrimental thresholds of Black ethnic density. We addressed these 2 study aims while accounting for, and adequately modeling, the potential suppressing effects of area resource deprivation on the association between ethnic density and an important mental health outcome.We selected depressive symptoms as the mental health outcome in this study because the literature is consistent regarding the ethnic density effects of outcomes such as psychoses, but not about the association between Black ethnic density and depression.5 Although the prevalence of major depression is lower among African Americans than among the White majority, the prevalence of depressive symptoms and chronic low mood is high among this population,12–14 and understanding any protective or risk factors of psychological distress, including at the neighborhood level, remains a priority.We focused on African Americans because most ethnic density studies have been conducted in this population, and it is the group in which ethnic density effects have been found to be the most detrimental.1,2 Some previous studies have modeled nonlinear associations between Black ethnic density and several physical health indicators,15–18 but not mental health ones. In all of these prior studies, potential cutoff points have not been based on formal threshold examinations. In addition, prior studies have analyzed non-Hispanic Black respondents. In this study, we focused specifically on African Americans because of the documented heterogeneity of sociodemographic characteristics,19 health profiles,20–22 and ethnic density effects23 in the non-Hispanic Black population.     

Risks and Benefits of Green Spaces for Children: A Cross-Sectional Study of Associations with Sedentary Behavior,Obesity, Asthma,and Allergy

Background: Green spaces have been associated with both health benefits and risks in children; however, available evidence simultaneously investigating these conflicting influences, especially in association with different types of greenness, is scarce.Objectives: We aimed to simultaneously evaluate health benefits and risks associated with different types of greenness in children, in terms of sedentary behavior (represented by excessive screen time), obesity, current asthma, and allergic rhinoconjunctivitis.Methods: We conducted a cross-sectional study of a population-based sample of 3,178 schoolchildren (9–12 years old) in Sabadell, Spain, in 2006. Information on outcomes and covariates was obtained by questionnaire. We measured residential surrounding greenness as the average of satellite-derived Normalized Difference Vegetation Index (NDVI) in buffers of 100 m, 250 m, 500 m, and 1,000 m around each home address. Residential proximity to green spaces was defined as living within 300 m of a forest or a park, as separate variables. We used logistic regression models to estimate associations separately for each exposure–outcome pair, adjusted for relevant covariates.Results: An interquartile range increase in residential surrounding greenness was associated with 11–19% lower relative prevalence of overweight/obesity and excessive screen time, but was not associated with current asthma and allergic rhinoconjunctivitis. Similarly, residential proximity to forests was associated with 39% and 25% lower relative prevalence of excessive screen time and overweight/obesity, respectively, but was not associated with current asthma. In contrast, living close to parks was associated with a 60% higher relative prevalence of current asthma, but had only weak negative associations with obesity/overweight or excessive screen time.Conclusion: We observed two separable patterns of estimated health benefits and risks associated with different types of greenness.Citation: Dadvand P, Villanueva CM, Font-Ribera L, Martinez D, Basagaña X, Belmonte J, Vrijheid M, Gražulevičienė R, Kogevinas M, Nieuwenhuijsen MJ. 2014. Risks and benefits of green spaces for children: a cross-sectional study of associations with sedentary behavior, obesity, asthma, and allergy. Environ Health Perspect 122:1329–1335; http://dx.doi.org/10.1289/ehp.1308038