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BACKGROUND: The aim of this study was to evaluate the recovery rate of the left ventricular systolic function of women diagnosed with peripartum cardiomyopathy receiving specialized care in rural Tanzania. METHODS: In this observational study, women diagnosed with peripartum cardiomyopathy at a referral center in rural Tanzania between December 2015 and September 2021 were included. Women diagnosed between February and September 2021 were followed prospectively, those diagnosed between December 2015 and January 2021 were tracked back for a follow-up echocardiography. All participants received a clinical examination, a comprehensive echocardiogram, and a prescription of guideline-directed medical therapy. The primary outcome was recovery of the left ventricular systolic function (left ventricular ejection fraction > 50%). RESULTS: Median age of the 110 participants was 28.5 years (range 17-45). At enrolment, 49 (45%) participants were already on cardiac medication, 50 (45%) had severe eccentric hypertrophy of the left ventricle, and the median left ventricular ejection fraction was 30% (range 15-46). After a median follow-up of 8.98 months (IQR 5.72-29.37), 61 (55%) participants were still on cardiac medication. Full recovery of the left ventricular systolic function was diagnosed in 76 (69%, 95% CI 59.6-77.6%) participants. In the multivariate analysis, a higher left ventricular ejection fraction at baseline was positively associated with full recovery (each 5% increase; OR 1.7, 95% CI 1.10-2.62, p = 0.012), while higher age was inversely associated (each 10 years increase; OR 0.40, 95% CI 0.19-0.82, p = 0.012). CONCLUSION: Left ventricular systolic function recovered completely in 69% of study participants with peripartum cardiomyopathy from rural Tanzania under specialized care.
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Cardiomiopatías , Periodo Periparto , Complicaciones Cardiovasculares del Embarazo , Recuperación de la Función , Volumen Sistólico , Sístole , Función Ventricular Izquierda , Humanos , Femenino , Adulto , Tanzanía/epidemiología , Adulto Joven , Adolescente , Embarazo , Cardiomiopatías/fisiopatología , Cardiomiopatías/diagnóstico por imagen , Cardiomiopatías/diagnóstico , Factores de Tiempo , Persona de Mediana Edad , Complicaciones Cardiovasculares del Embarazo/fisiopatología , Complicaciones Cardiovasculares del Embarazo/diagnóstico por imagen , Complicaciones Cardiovasculares del Embarazo/diagnóstico , Complicaciones Cardiovasculares del Embarazo/tratamiento farmacológico , Resultado del Tratamiento , Estudios Prospectivos , Salud Rural , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/diagnóstico , Trastornos Puerperales/fisiopatología , Trastornos Puerperales/diagnóstico , Trastornos Puerperales/terapia , Trastornos Puerperales/tratamiento farmacológicoRESUMEN
Importance: Agreement in lung ultrasonography findings between clinicians using a handheld ultrasonographic device and expert sonographers using a high-end ultrasonographic machine has not been studied in sub-Saharan Africa. Objective: To determine the agreement in ultrasonographic findings and diagnoses between primary care clinicians trained in lung ultrasonography, board-certified expert sonographers, and senior physicians. Design, Setting, and Participants: This cross-sectional single-center study was conducted from February 1, 2022, to April 30, 2023 at a referral center in rural Tanzania. Individuals 5 years or older with respiratory symptoms and at least 2 distinct respiratory signs or symptoms were eligible. A total of 459 individuals were screened. Exposures: Participants provided their medical history and underwent a clinical examination and lung ultrasonography performed by a clinician, followed by a lung ultrasonography performed by an expert sonographer, and finally chest radiography and a final evaluation performed by a senior physician. Other tests, such as echocardiography and Mycobacterium tuberculosis testing, were conducted on the decision of the physician. Clinicians received 2 hours of instruction and three 2-hour sessions of clinical training in the use of a handheld lung ultrasonographic device; expert sonographers were board-certified. Main Outcomes and Measures: Percentage agreement and Cohen κ coefficient for sonographic findings and diagnoses compared between clinicians and expert sonographers, and between clinicians and senior physicians. Results: The median (IQR) age of 438 included participants was 54 (38-66) years, and 225 (51%) were male. The median (range) percentage agreement of ultrasonographic findings between clinicians and expert sonographers was 93% (71%-99%), with κ ranging from -0.003 to 0.83. Median (range) agreement of diagnoses between clinicians and expert sonographers was 90% (50%-99%), with κ ranging from -0.002 to 0.76. Between clinicians and senior physicians, median (range) agreement of diagnoses was 89% (55%-90%), with κ ranging from -0.008 to 0.76. Between clinicians and senior physicians, diagnosis agreements were 85% (κ, 0.69) for heart failure, 78% (κ, 0.57) for definite or probable tuberculosis, 50% (κ, 0.002) for viral pneumonia, and 56% (κ, 0.06) for bacterial pneumonia. Conclusions and Relevance: In this cross-sectional study, the agreement of ultrasonographic findings between clinicians and sonographers was mostly substantial. Between clinicians and senior physicians, agreement was substantial in the diagnosis of heart failure, moderate in the diagnosis of tuberculosis, but slight in the diagnosis of pneumonia. These findings suggest that handheld ultrasonographic devices used in addition to clinical examination may support clinicians in diagnosing cardiac and pulmonary diseases in rural sub-Saharan Africa.
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Insuficiencia Cardíaca , Neumonía Viral , Tuberculosis , Masculino , Humanos , Persona de Mediana Edad , Anciano , Femenino , Estudios Transversales , Insuficiencia Cardíaca/diagnóstico por imagen , TanzaníaRESUMEN
AIMS: We previously observed that some individuals on HIV boosted protease inhibitor-containing regimen do not achieve their lipid targets despite elevated statin concentrations. This study evaluated whether the common single polymorphism c.521T>C in SLCO1B1, associated with reduced statin uptake in the liver, could explain this observation. METHODS: People living with HIV in the Swiss HIV Cohort Study were eligible if they were on a boosted protease inhibitor concomitantly with a statin for at least 6 months and if their SLCO1B1 genotype was available. Furthermore, their lipids had to be documented before and after the introduction of the statin. The statin efficacy was defined as % change in total cholesterol, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol and triglycerides levels after statin initiation compared to pretreatment levels. Lipid response was adjusted for differences in potency and dose between statins. RESULTS: In total, 88 people living with HIV were included, of whom 58, 28 and 2 carried the SLCO1B1 TT, TC and CC genotypes, respectively. The change in lipid levels after statin initiation tended to be lower in carriers of the polymorphism although the difference was not statistically significant (TT vs. TC/CC: total cholesterol: -11.7 vs. -4.8%; low-density lipoprotein- cholesterol: -20.6 vs. -7.4%; high-density lipoprotein-cholesterol: 1.6 vs. 0%; triglycerides: -11.5 vs. -7.9%). In the multiple linear regression, change in total cholesterol was inversely correlated with the total cholesterol level prestatin treatment (coefficient -6.60, 95% confidence interval: -9.63 to -3.56, P < .001). CONCLUSION: The lipid-lowering effect of statins tended to be attenuated by SLCO1B1 polymorphism and progressively declined as total cholesterol under the boosted protease inhibitor treatment decreased.
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Infecciones por VIH , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Inhibidores de Proteasas , Estudios de Cohortes , Antivirales/uso terapéutico , Triglicéridos , LDL-Colesterol , HDL-Colesterol , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/genética , Transportador 1 de Anión Orgánico Específico del Hígado/genéticaRESUMEN
BACKGROUND: Computerised decision-support systems (CDSSs) for antibiotic stewardship could help to assist physicians in the appropriate prescribing of antibiotics. However, high-quality evidence for their effect on the quantity and quality of antibiotic use remains scarce. The aim of our study was to assess whether a computerised decision support for antimicrobial stewardship combined with feedback on prescribing indicators can reduce antimicrobial prescriptions for adults admitted to hospital. METHODS: The Computerised Antibiotic Stewardship Study (COMPASS) was a multicentre, cluster-randomised, parallel-group, open-label superiority trial that aimed to assess whether a multimodal computerised antibiotic-stewardship intervention is effective in reducing antibiotic use for adults admitted to hospital. After pairwise matching, 24 wards in three Swiss tertiary-care and secondary-care hospitals were randomised (1:1) to the CDSS intervention or to standard antibiotic stewardship measures using an online random sequence generator. The multimodal intervention consisted of a CDSS providing support for choice, duration, and re-evaluation of antimicrobial therapy, and feedback on antimicrobial prescribing quality. The primary outcome was overall systemic antibiotic use measured in days of therapy per admission, using adjusted-hurdle negative-binomial mixed-effects models. The analysis was done by intention to treat and per protocol. The study was registered with ClinicalTrials.gov (identifier NCT03120975). FINDINGS: 24 clusters (16 at Geneva University Hospitals and eight at Ticino Regional Hospitals) were eligible and randomly assigned to control or intervention between Oct 1, 2018, and Dec 31, 2019. Overall, 4578 (40·2%) of 11 384 admissions received antibiotic therapy in the intervention group and 4142 (42·8%) of 9673 in the control group. The unadjusted overall mean days of therapy per admission was slightly lower in the intervention group than in the control group (3·2 days of therapy per admission, SD 6·2, vs 3·5 days of therapy per admission, SD 6·8; p<0·0001), and was similar among patients receiving antibiotics (7·9 days of therapy per admission, SD 7·6, vs 8·1 days of therapy per admission, SD 8·4; p=0·50). After adjusting for confounders, there was no statistically significant difference between groups for the odds of an admission receiving antibiotics (odds ratio [OR] for intervention vs control 1·12, 95% CI 0·94-1·33). For admissions with antibiotic exposure, days of therapy per admission were also similar (incidence rate ratio 0·98, 95% CI 0·90-1·07). Overall, the CDSS was used at least once in 3466 (75·7%) of 4578 admissions with any antibiotic prescription, but from the first day of antibiotic treatment for only 1602 (58·9%) of 2721 admissions in Geneva. For those for whom the CDSS was not used from the first day, mean time to use of CDSS was 8·9 days. Based on the manual review of 1195 randomly selected charts, transition from intravenous to oral therapy was significantly more frequent in the intervention group after adjusting for confounders (154 [76·6%] of 201 vs 187 [87%] of 215, +10·4%; OR 1·9, 95% CI 1·1-3·3). Consultations by infectious disease specialists were less frequent in the intervention group (388 [13·4%] of 2889) versus the control group (405 [16·9%] of 2390; OR 0·84, 95% CI 0·59-1·25). INTERPRETATION: An integrated multimodal computerised antibiotic stewardship intervention did not significantly reduce overall antibiotic use, the primary outcome of the study. Contributing factors were probably insufficient uptake, a setting with relatively low antibiotic use at baseline, and delays between ward admission and first CDSS use. FUNDING: Swiss National Science Foundation. TRANSLATIONS: For the French and Italian translations of the abstract see Supplementary Materials section.
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Antiinfecciosos , Programas de Optimización del Uso de los Antimicrobianos , Adulto , Antibacterianos/uso terapéutico , Programas de Optimización del Uso de los Antimicrobianos/métodos , Hospitales , Humanos , SuizaRESUMEN
Recently, several articles reported incidental findings at 2-[18F]FDG PET/CT in patients who have received COVID-19 vaccinations, including hypermetabolic axillary lymph nodes (HALNs) ipsilateral to the COVID-19 vaccine injection site which may cause diagnostic dilemmas. The aim of our work was to calculate the prevalence of this finding. A comprehensive computer literature search of PubMed/MEDLINE, Embase, and Cochrane library databases was performed to identify recently published articles that investigated the prevalence of HALNs detected by 2-[18F]FDG PET/CT after COVID-19 vaccination. Pooled prevalence of this finding was calculated through a meta-analytic approach. Nine recently published articles including 2354 patients undergoing 2-[18F]FDG PET/CT after recent COVID-19 vaccination have been included in the systematic review. Overall, HALNs ipsilateral to the vaccine injection site were frequent findings mainly due to vaccine-related immune response in most of the cases. The pooled prevalence of HALNs after COVID-19 vaccination was 37% (95% confidence interval: 27-47%) but with significant heterogeneity among the included studies. Physicians must be aware and recognize the significant frequency of HALNs at 2-[18F]FDG PET/CT related to immune response to vaccine injection. Larger studies are needed to confirm the findings of this systematic review and meta-analysis.
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BACKGROUND: Hospital healthcare workers (HCW), in particular those involved in the clinical care of COVID-19 cases, are presumably exposed to a higher risk of acquiring the disease than the general population. METHODS: Between April 16 and 30, 2020 we conducted a prospective, SARS-CoV-2 seroprevalence study in HCWs in Southern Switzerland. Participants were hospital personnel with varying COVID-19 exposure risk depending on job function and working site. They provided personal information (including age, sex, occupation, and medical history) and self-reported COVID-19 symptoms. Odds ratio (OR) of seropositivity to IgG antibodies was estimated by univariate and multivariate logistic regressions. FINDINGS: Among 4726 participants, IgG antibodies to SARS-CoV-2 were detected in 9.6% of the HCWs. Seropositivity was higher among HCWs working on COVID-19 wards (14.1% (11.9-16.5)) compared to other hospital areas at medium (10.7% (7.6-14.6)) or low risk exposure (7.3% (6.4-8.3)). OR for high vs. medium wards risk exposure was 1.42 (0.91-2.22), P = 0.119, and 1.98 (1.55-2.53), P<0.001 for high vs. low wards risk exposure. The same was for true for doctors and nurses (10.1% (9.0-11.3)) compared to other employees at medium (7.1% (4.8-10.0)) or low risk exposure (6.6% (5.0-8.4)). OR for high vs. medium profession risk exposure was 1.37 (0.89-2.11), P = 0.149, and 1.75 (1.28-2.40), P = 0.001 for high vs. low profession risk exposure. Moreover, seropositivity was higher among HCWs who had household exposure to COVID-19 cases compared to those without (18.7% (15.3-22.5) vs. 7.7% (6.9-8.6), OR 2.80 (2.14-3.67), P<0.001). INTERPRETATION: SARS-CoV-2 antibodies are detectable in up to 10% of HCWs from acute care hospitals in a region with high incidence of COVID-19 in the weeks preceding the study. HCWs with exposure to COVID-19 patients have only a slightly higher absolute risk of seropositivity compared to those without, suggesting that the use of PPE and other measures aiming at reducing nosocomial viral transmission are effective. Household contact with known COVID-19 cases represents the highest risk of seropositivity. FUNDING: Henry Krenter Foundation, Ente Ospedaliero Cantonale and Vir Biotechnology.
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COVID-19/complicaciones , COVID-19/patología , Osificación Heterotópica/etiología , Respiración Artificial , SARS-CoV-2 , Anciano , Enfermedad Crítica , Articulación del Codo/patología , Femenino , Articulación de la Cadera/patología , Humanos , Masculino , Oportunidad Relativa , Osificación Heterotópica/epidemiología , Prevalencia , Factores de Riesgo , Articulación del Hombro/patologíaRESUMEN
Prosthetic hip joint replacement is considered the operation of the 20th century because of its wide diffusion and good outcome. More than 1 million prostheses are implanted worldwide annually. Although hip arthroplasty is considered a safe procedure, different complications can occur in relation with surgery. Periprosthesic joint infection is the most feared for its morbidity for the patients, and for the economic costs it generates. Most surgical site infections after hip arthroplasty are related to frequent germs as Staphylococci or Enterobacteriaceae, while Propionibacterium infections are more rare and often challenging in diagnosis and therapy. We report a case of a 77-year-old diabetic overweight male patient who developed a periprosthetic hip infection due to P. avidum and P. acnes after a mini-invasive direct anterior approach. To our knowledge, this represents the first case of chronic periprosthetic hip joint co-infection.
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BACKGROUND: Prevalence of potential drug-drug interactions (PDDIs) between antiretroviral drugs (ARVs) and co-medications was high in 2008 in a Swiss HIV Cohort Study (SHCS) survey. We reassessed the prevalence of PDDIs in the era of human immunodeficiency virus (HIV) integrase inhibitors (INIs), characterized by more favorable interaction profiles. METHODS: The prevalence of PDDIs in treated HIV-positive individuals was assessed for the period 01-12/2018 by linkage of the Liverpool HIV drug interactions and SHCS databases. PDDIs were categorized as harmful (red flagged), of potential clinical relevance (amber flagged), or of weak clinical significance (yellow flagged). RESULTS: In 9298 included individuals, median age was 51 years (IQR, 43-58), and 72% were males. Individuals received unboosted INIs (40%), boosted ARVs (30%), and nonnucleoside reverse transcriptase inhibitor (NNRTIs) (32%)-based regimens. In the entire cohort, 68% receivedâ ≥1 co-medication, 14% had polypharmacy (≥5 co-medications) and 29% hadâ ≥1 PDDI. Among individuals with co-medication, the prevalence of combined amber and yellow PDDIs was 43% (33% amber-mostly with cardiovascular drugs-and 20% yellow-flagged PDDIs) compared to 59% in 2008. Two percent had red-flagged PDDIs (mostly with corticosteroids), the same as in the 2008 survey. Compared with 2008, fewer individuals received boosted ARVs (-24%) and NNRTIs (-13%) but the use of co-medications was higher. CONCLUSIONS: Prevalence of PDDIs was lower with more widespread use of INIs in 2018 than in 2008. Continued use of boosted regimens and increasing needs for co-medications in this aging population impeded lower rates of PDDIs.
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Infecciones por VIH , Inhibidores de Integrasa VIH , Preparaciones Farmacéuticas , Anciano , Estudios de Cohortes , Interacciones Farmacológicas , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Inhibidores de Integrasa VIH/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Suiza/epidemiologíaRESUMEN
BACKGROUND: The extent of inappropriate prescribing observed in geriatric medicine has not been thoroughly evaluated in people ageing with HIV. We determined the prevalence of and risk factors for inappropriate prescribing in individuals aged ≥75 years enrolled in the Swiss HIV Cohort Study. METHODS: Retrospective review of medical records was performed to gain more insights into non-HIV comorbidities. Inappropriate prescribing was screened using the Beers criteria, the STOPP/START criteria and the Liverpool drug-drug interactions (DDIs) database. RESULTS: For 175 included individuals, the median age was 78 years (IQR 76-81) and 71% were male. The median number of non-HIV comorbidities was 7 (IQR 5-10). The prevalence of polypharmacy and inappropriate prescribing was 66% and 67%, respectively. Overall, 40% of prescribing issues could have deleterious consequences. Prescribing issues occurred mainly with non-HIV drugs and included: incorrect dosage (26%); lack of indication (21%); prescription omission (drug not prescribed although indicated) (17%); drug not appropriate in elderly individuals (18%) and deleterious DDIs (17%). In the multivariable logistic regression, risk factors for prescribing issues were polypharmacy (OR: 2.5; 95% CI: 1.3-4.7), renal impairment (OR: 2.7; 95% CI: 1.4-5.1), treatment with CNS-active drugs (OR: 2.1; 95% CI: 1.1-3.8) and female sex (OR: 8.3; 95% CI: 2.4-28.1). CONCLUSIONS: Polypharmacy and inappropriate prescribing are highly prevalent in elderly people living with HIV. Women are at higher risk than men, partly explained by sex differences in the occurrence of non-HIV comorbidities and medical care. Medication reconciliation and periodic review of prescriptions by experienced physicians could help reduce polypharmacy and inappropriate prescribing in this vulnerable, growing population.
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Infecciones por VIH , Prescripción Inadecuada , Anciano , Estudios de Cohortes , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , Humanos , Masculino , Polifarmacia , Estudios Retrospectivos , Suiza/epidemiologíaRESUMEN
PURPOSE: The length of time a critically ill coronavirus disease 2019 (COVID-19) patient remains infectious and should therefore be isolated remains unknown. This prospective study was undertaken in critically ill patients to evaluate the reliability of single negative real-time polymerase chain reaction (RT-PCR) in lower tracheal aspirates (LTA) in predicting a second negative test and to analyze clinical factors potentially influencing the viral shedding. METHODS: From April 9, 2020 onwards, intubated COVID-19 patients treated in the intensive care unit were systematically evaluated for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by RT-PCR of nasopharyngeal swabs and LTA. The time to negativity was defined as the time between the onset of symptoms and the viral clearance in LTA. In order to identify risk factors for prolonged viral shedding, we used univariate and multivariate Cox proportional hazards models. RESULTS: Forty-eight intubated SARS-CoV-2 patients were enrolled. Overall, we observed that the association of the first negative RT-PCR with a second negative result was 96.7%. Median viral shedding was 25 (IQR: 21.5-28) days since symptoms' onset. In the univariate Cox model analysis, type 2 diabetes mellitus was associated with a prolonged viral RNA shedding (hazard ratio [HR]: 0.41, 95% CI: 0.06-3.11, p = 0.04). In the multivariate Cox model analysis, type 2 diabetes was associated with a prolonged viral RNA shedding (HR: 0.31, 95% CI: 0.11-0.89, p = 0.029). CONCLUSION: Intubated patients with type 2 diabetes mellitus may have prolonged SARS-CoV-2 shedding. In critically ill COVID-19 patients, one negative LTA should be sufficient to assess and exclude infectivity.
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Betacoronavirus/fisiología , Infecciones por Coronavirus/virología , Enfermedad Crítica , Diabetes Mellitus Tipo 2/virología , Neumonía Viral/virología , Sistema Respiratorio/virología , Esparcimiento de Virus , Anciano , Betacoronavirus/genética , COVID-19 , Prueba de COVID-19 , Vacunas contra la COVID-19 , Técnicas de Laboratorio Clínico/métodos , Técnicas de Laboratorio Clínico/normas , Comorbilidad , Infecciones por Coronavirus/complicaciones , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/epidemiología , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiología , Progresión de la Enfermedad , Femenino , Humanos , Unidades de Cuidados Intensivos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/complicaciones , Neumonía Viral/diagnóstico , Neumonía Viral/epidemiología , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Reproducibilidad de los Resultados , Sistema Respiratorio/patología , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa/métodos , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa/normas , Factores de Riesgo , SARS-CoV-2 , Manejo de Especímenes/métodos , Manejo de Especímenes/normas , Suiza/epidemiología , Factores de TiempoRESUMEN
Analysis of the specificity and kinetics of neutralizing antibodies (nAbs) elicited by SARS-CoV-2 infection is crucial for understanding immune protection and identifying targets for vaccine design. In a cohort of 647 SARS-CoV-2-infected subjects, we found that both the magnitude of Ab responses to SARS-CoV-2 spike (S) and nucleoprotein and nAb titers correlate with clinical scores. The receptor-binding domain (RBD) is immunodominant and the target of 90% of the neutralizing activity present in SARS-CoV-2 immune sera. Whereas overall RBD-specific serum IgG titers waned with a half-life of 49 days, nAb titers and avidity increased over time for some individuals, consistent with affinity maturation. We structurally defined an RBD antigenic map and serologically quantified serum Abs specific for distinct RBD epitopes leading to the identification of two major receptor-binding motif antigenic sites. Our results explain the immunodominance of the receptor-binding motif and will guide the design of COVID-19 vaccines and therapeutics.
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Anticuerpos Neutralizantes/inmunología , Mapeo Epitopo/métodos , Glicoproteína de la Espiga del Coronavirus/inmunología , Enzima Convertidora de Angiotensina 2 , Anticuerpos Monoclonales/química , Anticuerpos Monoclonales/genética , Anticuerpos Monoclonales/inmunología , Anticuerpos Neutralizantes/sangre , Anticuerpos Neutralizantes/química , Anticuerpos Antivirales/sangre , Anticuerpos Antivirales/química , Anticuerpos Antivirales/inmunología , Reacciones Antígeno-Anticuerpo , Betacoronavirus/inmunología , Betacoronavirus/aislamiento & purificación , Betacoronavirus/metabolismo , Sitios de Unión , COVID-19 , Infecciones por Coronavirus/patología , Infecciones por Coronavirus/virología , Epítopos/química , Epítopos/inmunología , Humanos , Inmunoglobulina A/sangre , Inmunoglobulina A/inmunología , Inmunoglobulina G/sangre , Inmunoglobulina G/inmunología , Inmunoglobulina M/sangre , Inmunoglobulina M/inmunología , Cinética , Simulación de Dinámica Molecular , Pandemias , Peptidil-Dipeptidasa A/química , Peptidil-Dipeptidasa A/metabolismo , Neumonía Viral/patología , Neumonía Viral/virología , Unión Proteica , Dominios Proteicos/inmunología , Estructura Cuaternaria de Proteína , SARS-CoV-2 , Glicoproteína de la Espiga del Coronavirus/química , Glicoproteína de la Espiga del Coronavirus/genética , Glicoproteína de la Espiga del Coronavirus/metabolismoAsunto(s)
Anticoagulantes/efectos adversos , Infecciones por Coronavirus/terapia , Fibrinolíticos/efectos adversos , Hemorragia/inducido químicamente , Neumonía Viral/terapia , Trombosis/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Anticoagulantes/administración & dosificación , Betacoronavirus/patogenicidad , COVID-19 , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/virología , Femenino , Fibrinolíticos/administración & dosificación , Hemorragia/epidemiología , Interacciones Huésped-Patógeno , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/epidemiología , Neumonía Viral/virología , Prevalencia , Factores de Riesgo , SARS-CoV-2 , Suiza/epidemiología , Trombosis/epidemiología , Trombosis/virología , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenAsunto(s)
Coinfección , Infecciones por Coronavirus , Pandemias , Neumonía Viral , Antibacterianos , Betacoronavirus , COVID-19 , Enfermedad Crítica , Humanos , SARS-CoV-2RESUMEN
We report the uncommon clinical case of our patient, an 83-year-old woman with Alzheimer disease, who acquired a potentially fatal tropical infection in an open-air swimming pool in the Alps. Chromobacterium violaceum is a rare gram-negative anaerobe bacillus, generally associated with serious waterborne infections in tropical and subtropical regions. The patient presented to our emergency department with a 2-day history of fever and a small non-necrotic wound on the right leg after a minor injury 9 days before. It turned out to be the first infection in Switzerland due to C. violaceum, a deadly bacterium typical of tropical regions. C. violaceum appeared for the first time in Europe in the 2011. This is now the third documented case in less than a year and the second autochthonous infection ever in our continent. A delay in adequate treatment of this emerging pathogen may be associated with high fatality rates.
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Bacteriemia , Infecciones por Bacterias Gramnegativas , Anciano de 80 o más Años , Bacteriemia/diagnóstico , Bacteriemia/tratamiento farmacológico , Chromobacterium , Femenino , Infecciones por Bacterias Gramnegativas/diagnóstico , Infecciones por Bacterias Gramnegativas/tratamiento farmacológico , Humanos , SuizaRESUMEN
Background: Computerized decision support systems (CDSS) provide new opportunities for automating antimicrobial stewardship (AMS) interventions and integrating them in routine healthcare. CDSS are recommended as part of AMS programs by international guidelines but few have been implemented so far. In the context of the publicly funded COMPuterized Antibiotic Stewardship Study (COMPASS), we developed and implemented two CDSSs for antimicrobial prescriptions integrated into the in-house electronic health records of two public hospitals in Switzerland. Developing and implementing such systems was a unique opportunity for learning during which we faced several challenges. In this narrative review we describe key lessons learned. Recommendations: (1) During the initial planning and development stage, start by drafting the CDSS as an algorithm and use a standardized format to communicate clearly the desired functionalities of the tool to all stakeholders. (2) Set up a multidisciplinary team bringing together Information Technologies (IT) specialists with development expertise, clinicians familiar with "real-life" processes in the wards and if possible, involve collaborators having knowledge in both areas. (3) When designing the CDSS, make the underlying decision-making process transparent for physicians and start simple and make sure to find the right balance between force and persuasion to ensure adoption by end-users. (4) Correctly assess the clinical and economic impact of your tool, therefore try to use standardized terminologies and limit the use of free text for analysis purpose. (5) At the implementation stage, plan usability testing early, develop an appropriate training plan suitable to end users' skills and time-constraints and think ahead of additional challenges related to the study design that may occur (such as a cluster randomized trial). Stay also tuned to react quickly during the intervention phase. (6) Finally, during the assessment stage plan ahead maintenance, adaptation and related financial challenges and stay connected with institutional partners to leverage potential synergies with other informatics projects.
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BACKGROUND: Patients with suspected tuberculosis are often overtreated with antituberculosis drugs. We evaluated the diagnostic value of the focused assessment with sonography for HIV-associated tuberculosis (FASH) in rural Tanzania. METHODS: In a prospective cohort study, the frequency of FASH signs was compared between patients with confirmed tuberculosis and those without tuberculosis. Clinical and laboratory examination, chest x-ray, Xpert MTB/RIF assay, and culture from sputum, sterile body fluids, lymph node aspirates, and Xpert MTB/RIF urine assay was done. RESULTS: Of 191 analyzed patients with a 6-month follow-up, 52.4% tested positive for human immunodeficiency virus, 21.5% had clinically suspected pulmonary tuberculosis, 3.7% had extrapulmonary tuberculosis, and 74.9% had extrapulmonary and pulmonary tuberculosis. Tuberculosis was microbiologically confirmed in 57.6%, probable in 13.1%, and excluded in 29.3%. Ten of eleven patients with splenic or hepatic hypoechogenic lesions had confirmed tuberculosis. In a univariate model, abdominal lymphadenopathy was significantly associated with confirmed tuberculosis. Pleural- and pericardial effusion, ascites, and thickened ileum wall lacked significant association. In a multiple regression model, abnormal chest x-ray (odds ratio [OR] = 6.19; 95% confidence interval [CI], 1.96-19.6; P < .002), ≥1 FASH-sign (OR = 3.33; 95% CI, 1.21-9.12; P = .019), and body temperature (OR = 2.48; 95% CI, 1.52-5.03; P = .001 per °C increase) remained associated with tuberculosis. A combination of ≥1 FASH sign, abnormal chest x-ray, and temperature ≥37.5°C had 99.1% sensitivity (95% CI, 94.9-99.9), 35.2% specificity (95% CI, 22.7-49.4), and a positive and negative predictive value of 75.2% (95% CI, 71.3-78.7) and 95.0% (95% CI, 72.3-99.3). CONCLUSIONS: The absence of FASH signs combined with a normal chest x-ray and body temperature <37.5°C might exclude tuberculosis.
RESUMEN
Tularemia is a zoonosis caused by the infection of Francisella tularensis (a gram-negative aerobic bacterium). Transmission to other animals or humans usually occurs through insect or tick bites, direct contact with a contaminated environment (mud or water), infected animals - mainly lagomorphs - or by ingesting undercooked meat or inhaling contaminated dust (hay or soil). This paper discusses the case of a 32-year-old man, who came to our Emergency Room presenting with persistent fever, inguinal lymphadenopathy, and an ulcer on his left lower limb on a linear morphoea lesion that had been there for some time. The lesion was surrounded by erysipelas. After hospitalization and tests, the patient was diagnosed with ulceroglandular tularemia. Antibiotic treatment with doxycycline resolved the clinical picture, but not the morphoea lesion.