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BACKGROUND: EMS frequently encounter patients who decline transport, yet there are little data to inform the safety of patient and/or paramedic-initiated assess, treat, and refer (ATR) protocols. We determined patient decision-making and short-term outcomes after non-transport by EMS during the COVID-19 pandemic. METHODS: This was a prospective, observational study of a random sample of patients evaluated and not transported by EMS from August 2020 to March 2021. From the EMS database, we randomly selected a daily sample of adult patients with disposition of ATR. We excluded patients dispositioned against medical advice (AMA) and those in police custody. Investigators contacted patients by phone to administer a standardized survey regarding decision-making, symptom progression, follow-up care, and satisfaction with non-transport decision. We also determined the proportion of patients who re-contacted 9-1-1 within 72 h, and unexpected deaths within 72 h using coroner data. Descriptive statistics were calculated. RESULTS: Of 4613 non-transported patients, 3330 (72%) patients for whom the disposition was ATR were included. Patients were 46% male with a median age of 49 (inter-quartile range (IQR) 31-67). Median vital signs measurements fell within the normal range. Investigators successfully contacted 584/3330 patients (18%). The most common reason for failure was lack of accurate phone number. The most common reasons patients reported for not going to the ED on initial encounter were: felt reassured after the paramedic assessment (151/584, 26%), medical complaint resolved (113/584, 19%), paramedic suggested transport was not required (73/584, 13%), concern for COVID-19 exposure (57/584, 10%), and initial concern was not medical (46/584, 8%). Ninety-five percent (552/584) were satisfied with the non-transport decision and 49% (284/584) had sought follow-up care. The majority (501/584, 86%) reported equal, improved, or resolved symptoms, while 80 patients (13%) reported worse symptoms, of whom (64/80, 80%) remained satisfied with the non-transport decision. Overall, there were 154 of 3330 (4.6%) 9-1-1 recontacts within 72 h. Based on coroner data, three unexpected deaths (0.09%) occurred within 72 h of the initial EMS calls. CONCLUSION: Paramedic disposition by ATR protocols resulted in a low rate of 9-1-1 recontact. Unexpected deaths were extremely rare. Patient satisfaction with the non-transport decision was high.
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COVID-19 , Serviços Médicos de Emergência , Adulto , Humanos , Masculino , Feminino , Paramédico , Estudos Prospectivos , PandemiasRESUMO
A fundamental problem for the evolution of pregnancy, the most specialized form of parental investment among vertebrates, is the rejection of the nonself-embryo. Mammals achieve immunological tolerance by down-regulating both major histocompatibility complex pathways (MHC I and II). Although pregnancy has evolved multiple times independently among vertebrates, knowledge of associated immune system adjustments is restricted to mammals. All of them (except monotremata) display full internal pregnancy, making evolutionary reconstructions within the class mammalia meaningless. Here, we study the seahorse and pipefish family (syngnathids) that have evolved male pregnancy across a gradient from external oviparity to internal gestation. We assess how immunological tolerance is achieved by reconstruction of the immune gene repertoire in a comprehensive sample of 12 seahorse and pipefish genomes along the "male pregnancy" gradient together with expression patterns of key immune and pregnancy genes in reproductive tissues. We found that the evolution of pregnancy coincided with a modification of the adaptive immune system. Divergent genomic rearrangements of the MHC II pathway among fully pregnant species were identified in both genera of the syngnathids: The pipefishes (Syngnathus) displayed loss of several genes of the MHC II pathway while seahorses (Hippocampus) featured a highly divergent invariant chain (CD74). Our findings suggest that a trade-off between immunological tolerance and embryo rejection accompanied the evolution of unique male pregnancy. That pipefishes survive in an ocean of microbes without one arm of the adaptive immune defense suggests a high degree of immunological flexibility among vertebrates, which may advance our understanding of immune-deficiency diseases.
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Evolução Biológica , Reprodução/genética , Smegmamorpha/genética , Smegmamorpha/fisiologia , Animais , Feminino , Humanos , Masculino , Reprodução/fisiologia , Comportamento Sexual Animal/fisiologiaRESUMO
BACKGROUND: Many trauma centers have adopted routine head-to-pelvis computed tomography (CT) imaging for the evaluation of adults with blunt trauma. OBJECTIVE: We sought to determine the yields of detecting clinically significant injuries (CSIs) with CT in >1 anatomic region. METHODS: We conducted this observational cohort study of all trauma activation patients >14 years of age who received CT imaging during blunt trauma evaluation at a Level 1 trauma center from April to October 2014. Expert panels determined the clinical significance of head, neck, chest, abdomen, and pelvis injuries seen on CT. We calculated yields of CSI, defined as the number of patients with CSI divided by the total number of patients who underwent CT imaging. The 3 specified anatomic regions considered were head/neck, chest, and abdomen/pelvis. RESULTS: The median age of 1236 patients who had CT was 48 years; 69% were male; 51.2% were admitted; and hospital mortality was 4.4%. Yields of CSI with 95% confidence intervals (CIs) were: head/neck region injury 11.3% (9.6-13.3%); chest region injury only 7.9% (6.0-10.4%); abdomen/pelvis region injury only 5.1% (3.7-7.0%); both head/neck and chest CSI 2.8% (1.7-4.5%); both head/neck and abdomen/pelvis CSI 1.6% (0.9-2.9%); and both chest and abdomen/pelvis CSI 1.1% (0.5-2.4%). The yield of CSI in all 3 anatomic regions with head-to-pelvis CT was 0.6% (0.2-1.7%), and 76.7% (68.8-83.1%) of CSIs occurred in isolation. CONCLUSIONS: During multiple anatomic region CT imagng for adult blunt trauma evaluation, the yield for CSI in >1 region is low. In low-risk populations, selective CT imaging of anatomic regions (instead of reflexive head-to-pelvis CT imaging) may be more appropriate.
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Traumatismos Abdominais/diagnóstico , Tomada de Decisão Clínica/métodos , Traumatismos Craniocerebrais/diagnóstico , Traumatismos Torácicos/diagnóstico , Tomografia Computadorizada por Raios X/métodos , Traumatismos Abdominais/epidemiologia , Adulto , Idoso , Estudos de Coortes , Traumatismos Craniocerebrais/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Traumatismos Torácicos/epidemiologia , Tomografia Computadorizada por Raios X/normas , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricosRESUMO
BACKGROUND: Direct-acting antivirals (DAAs) against hepatitis C virus (HCV) have been described as revolutionary. However, it remains uncertain how effective these drugs will be for individuals coinfected with human immunodeficiency virus (HIV)-HCV. Bridging this gap between efficacy and effectiveness requires a focus on the generalizability of clinical trials. METHODS: Generalizability of DAA trials was assessed by applying the eligibility criteria from 5 efficacy trials: NCT01479868, PHOTON-1 (NCT01667731), TURQUOISE-I (NCT01939197), ION-4 (NCT02073656), and ALLY-2 (NCT02032888) that evaluated simeprevir; sofosbuvir; ombitasvir, paritaprevir/ritonavir/dasabuvir; sofosbuvir/ledipasvir; and daclatasvir/sofosbuvir, respectively, to the Canadian Coinfection Cohort, representing approximately 23% of the total coinfected population in care in Canada. RESULTS: Of 874 active participants, 70% had chronic HCV, of whom 410, 26, 94, and 11 had genotypes 1, 2, 3, and 4, respectively. After applying trial eligibility criteria, only 5.9% (24/410) would have been eligible for enrollment in the simeprevir trial, 9.8% (52/530) in PHOTON-1, 6.3% (26/410) in TURQUOISE-I, and 8.1% (34/421) in ION-4. The ALLY-2 study was more inclusive; 43% (233/541) of the cohort would have been eligible. The most exclusive eligibility criteria across all trials with the exception of ALLY-2 were restriction to specific antiretroviral therapies (63%-79%) and active illicit drug use (53%-55%). CONCLUSIONS: DAA trial results may have limited generalizability, since the majority of coinfected individuals were not eligible to participate. Exclusions appeared to be related to improving treatment outcomes by not including those at higher risk of poor adherence and reinfection--individuals for whom real-world data are urgently needed.
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Antivirais/uso terapêutico , Ensaios Clínicos como Assunto/normas , Coinfecção/tratamento farmacológico , Infecções por HIV , Hepatite C , Adulto , Idoso , Estudos de Coortes , Feminino , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Hepatite C/complicações , Hepatite C/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
PURPOSE: More severe influenza disease and poor vaccine immunogenicity is reported in HIV-infected patients. We measured antibody avidity after influenza vaccination in HIV patients to assess vaccine efficacy. METHODS: Two dosing strategies (Group1: single dose, n = 28. Group2: single dose plus booster, n = 36) with an AS03A-adjuvanted H1N12009 pandemic influenza vaccine (Arepanrix, GSK) were assessed in HIV patients. Serum hemagglutination inhibition (HAI) titers and antibody avidity reported as an avidity index (AI) were measured at days 21 and 42 and at 6 months. RESULTS: Baseline HIV parameters were similar among all participants. Eighteen participants had measurable baseline HAI titers. In these subjects, AI was at ~9 at baseline and was not significantly increased by one or two vaccine doses. In those without detectable baseline antibodies, immunization induced modest antibody titers [Group1 HAI, 61 (26-144); Group2 HAI, 46 (28-76)] with high AI after one dose at day 21 [Group1 AI, 8.8 (7.3-10.7); Group2 AI, 8.9 (7.8-10.1)]. A second dose of vaccine generated significantly higher HAI titers at day 42 [Group1 HAI, 41 (18-90); Group2 HAI, 92 (64-132)] and persisted to 6 months [Group1 HAI, 9 (6-13); Group2 HAI, 19 (13-30)]. All subjects who produced detectable HAI titers after vaccination generated high antibody avidity (AI, 9-10), which persisted up to 6 months. CONCLUSION: In participants initially seronegative, two doses of vaccine enabled a greater percentage of subjects to respond to the vaccine and elicited higher HAI titers. All subjects who produced detectable HAI titers also rapidly generated high AI in the short and long term. We demonstrate that high avidity antibodies can be achieved after vaccination and support a two-dose immunization strategy for HIV-positive subjects.
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Anticorpos Antivirais , Infecções por HIV/imunologia , HIV/imunologia , Vírus da Influenza A/imunologia , Vacinas contra Influenza , Influenza Humana/imunologia , Polissorbatos , Esqualeno , alfa-Tocoferol , Adulto , Anticorpos Antivirais/sangue , Afinidade de Anticorpos , Combinação de Medicamentos , Feminino , Infecções por HIV/complicações , Soropositividade para HIV , Humanos , Imunização Secundária , Influenza Humana/complicações , Masculino , Vacinação em Massa , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
Helminth parasites of teleost fish have evolved strategies to evade and manipulate the immune responses of their hosts. Responsiveness of fish host immunity to helminth antigens may therefore vary depending on the degree of host-parasite counter-adaptation. Generalist parasites, infective for a number of host species, might be unable to adapt optimally to the immune system of a certain host species, while specialist parasites might display high levels of adaptation to a particular host species. The degree of adaptations may further differ between sympatric and allopatric host-parasite combinations. Here, we test these hypotheses by in vitro exposure of head kidney leukocytes from three-spined sticklebacks (Gasterosteus aculeatus) to antigens from parasites with a broad fish host range (Diplostomum pseudospathaceum, Triaenophorus nodulosus), a specific fish parasite of cyprinids (Ligula intestinalis) and parasites highly specific only to a single fish species as second intermediate host (Schistocephalus pungitii, which does not infect G. aculeatus, and Schistocephalus solidus, infecting G. aculeatus). In vitro responses of stickleback leukocytes to S. solidus antigens from six European populations, with S. solidus prevalence from <1% to 66% were tested in a fully crossed experimental design. Leukocyte cultures were analysed by means of flow cytometry and a chemiluminescence assay to quantify respiratory burst activity. We detected decreasing magnitudes of in vitro responses to antigens from generalist to specialist parasites and among specialists, from parasites that do not infect G. aculeatus to a G. aculeatus-infecting species. Generalist parasites seem to maintain their ability to infect different host species at the costs of relatively higher immunogenicity compared to specialist parasites. In a comparison of sympatric and allopatric combinations of stickleback leukocytes and antigens from S. solidus, magnitudes of in vitro responses were dependent on the prevalence of the parasite in the population of origin, rather than on sympatry. Antigens from Norwegian (prevalence 30-50%) and Spanish (40-66%) S. solidus induced generally higher in vitro responses compared to S. solidus from two German (<1%) populations. Likewise, leukocytes from stickleback populations with a high S. solidus prevalence showed higher in vitro responses to S. solidus antigens compared to populations with low S. solidus prevalence. This suggests a rather low degree of local adaptation in S. solidus populations, which might be due to high gene flow among populations because of their extremely mobile final hosts, fish-eating birds.
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Doenças dos Peixes/parasitologia , Smegmamorpha , Trematódeos/imunologia , Infecções por Trematódeos/veterinária , Animais , Doenças dos Peixes/imunologia , Citometria de Fluxo , Interações Hospedeiro-Parasita/imunologia , Neutrófilos , Explosão Respiratória/imunologia , Infecções por Trematódeos/epidemiologia , Infecções por Trematódeos/parasitologiaRESUMO
BACKGROUND: The prevalence of cannabis use in HIV-infected individuals is high and its long-term effects are unclear. METHODS: The prevalence, perceived benefits and consequences, and predictors of cannabis use were studied using a cross-sectional survey in two immunodeficiency clinics in Maritime Canada. RESULTS: Current cannabis use was identified in 38.5% (87 of 226) of participants. Almost all cannabis users (85 of 87 [97.7%]) acknowledged its use for recreational purposes, with 21.8% (19 of 87) reporting medicinal cannabis use. The majority of patients enrolled in the present study reported mild or no symptoms related to HIV (n=179). Overall, 80.5% (70 of 87) of the cannabis-using participants reported a symptom-relieving benefit, mostly for relief of stress, anorexia or pain. Participants consumed a mean (± SD) of 18.3±21.1 g of cannabis per month and spent an average of $105.15±109.87 on cannabis per month. Cannabis use was associated with rural residence, lower income level, driving under the influence of a substance, and consumption of ecstasy and tobacco. Income level, ecstasy use and tobacco use were retained as significant predictors in regression modelling. Cannabis use was not associated with adverse psychological outcomes. DISCUSSION: Prolonged previous cannabis consumption and the substantial overlap between recreational and medicinal cannabis use highlight the challenges in obtaining a tenable definition of medicinal cannabis therapy.
HISTORIQUE: La prévalence de consommation de cannabis est élevée chez les personnes infectées par le VIH, mais on n'en connaît pas les effets à long terme. MÉTHODOLOGIE: Les chercheurs ont étudié la prévalence, les avantages perçus et les conséquences et prédicteurs de consommation de cannabis au moyen d'un sondage transversal mené dans deux cliniques d'immunodéficience des Maritimes, au Canada. RÉSULTATS: Les chercheurs ont constaté une consommation courante de cannabis chez 38,5 % des participants (87 sur 226). Presque tous les consommateurs de cannabis (85 sur 87 [97,7 %]) admettaient en prendre pour des fins récréatives, et 21,8 % (19 sur 87) indiquaient en prendre pour des fins médicinales. La majorité des patients qui participaient à la présente étude a déclaré des symptômes du VIH légers, sinon inexistants (n=179). Dans l'ensemble, 80,5 % des participants consommateurs de cannabis (70 sur 87) ont affirmé remarquer un soulagement des symptômes, particulièrement le stress, l'anorexie ou la douleur. Les participants consommaient en moyenne 18,3±21,1 g de cannabis par mois et dépensaient en moyenne 105,15±109,87 $ par mois pour se le procurer. La consommation de cannabis était liée à un logement en milieu rural, à un niveau de revenu plus bas, à la conduite sous l'influence d'une substance et à la consommation d'ecstasy et de tabac. Le niveau de revenu, la consommation d'ecstasy et la consommation de tabac étaient considérés comme des prédicteurs importants selon le modèle de régression. La consommation de cannabis ne s'associait pas à des résultats psychologiques indésirables. EXPOSÉ: Une consommation antérieure prolongée de cannabis et le chevauchement important entre la consommation de cannabis à des fins récréatives et médicinales font ressortir la difficulté d'obtenir une définition viable du traitement médicinal par le cannabis.
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The major histocompatibility complex (MHC)-mediated adaptive immune system is the hallmark of gnathostome immune defence. Recent work suggests that cod-like fishes (Gadidae) lack important components of the MHC class II mediated immunity. Here, we report a putative independent loss of functionality of this pathway in another species, the pipefish Syngnathus typhle, that belongs to a distantly related fish family (Syngnathidae). In a deep transcriptome sequencing approach comprising several independent normalized and non-normalized expressed sequence tag (EST) libraries with approximately 7.5 × 10(8) reads, sequenced with two next generation platforms (454 and Illumina), we were unable to identify MHC class IIα/ß genes as well as genes encoding associated receptors. Along with the recent findings in cod, our results suggest that immune systems of the Euteleosts may be more variable than previously assumed.
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Peixes/imunologia , Perfilação da Expressão Gênica , Genes MHC da Classe II , Vibrioses/veterinária , Animais , Comportamento Animal , Evolução Biológica , Clonagem Molecular , Biologia Computacional , Etiquetas de Sequências Expressas , Peixes/genética , Peixes/microbiologia , Biblioteca Gênica , Brânquias/imunologia , Brânquias/microbiologia , Brânquias/patologia , Sequenciamento de Nucleotídeos em Larga Escala , Especificidade da Espécie , Transcriptoma , Vibrio/imunologia , Vibrio/patogenicidade , Vibrioses/imunologia , Vibrioses/microbiologiaRESUMO
BACKGROUND: Although some studies show higher antiretroviral concentrations in women compared to men, data are limited. We conducted a cross-sectional study of HIV-positive women to determine if protease inhibitor (PI) and non-nucleoside reverse transcriptase inhibitor (NNRTI) C(min) and Cmax values were significantly different than historical general population (predominantly male) averages and to evaluate correlates of higher concentrations. METHODS: HIV-positive women with virologic suppression (viral load < 50copies/mL) on their first antiretroviral regimen were enrolled. Timed blood samples for C(min) and Cmax were drawn weekly for 3 weeks. The ratio of each individual's median C(min) and Cmax to the published population mean values for their PI or NNRTI was calculated and assessed using Wilcoxon sign-rank. Intra- and inter-patient variability of antiretroviral drug levels was assessed using coefficient of variation and intra-class correlation. Linear regression was used to identify correlates of the square root-transformed C(min) and Cmax ratios. RESULTS: Data from 82 women were analyzed. Their median age was 41 years (IQR=36-48) and duration of antiretrovirals was 20 months (IQR=9-45). Median antiretroviral C(min) and Cmax ratios were 1.21 (IQR=0.72-1.89, p=0.003) (highest ratios for nevirapine and lopinavir) and 0.82 (IQR=0.59-1.14, p=0.004), respectively. Nevirapine and efavirenz showed the least and unboosted atazanavir showed the most intra- and inter-patient variability. Higher CD4+ count correlated with higher C(min). No significant correlates for Cmax were found. CONCLUSIONS: Compared to historical control data, C(min) in the women enrolled was significantly higher whereas Cmax was significantly lower. Antiretroviral C(min) ratios were highly variable within and between participants. There were no clinically relevant correlates of drug concentrations. TRIAL REGISTRATION: NCT00433979.
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Antirretrovirais/farmacocinética , Infecções por HIV/metabolismo , Adulto , Alcinos , Antirretrovirais/sangue , Antirretrovirais/uso terapêutico , Sulfato de Atazanavir , Benzoxazinas/sangue , Benzoxazinas/farmacocinética , Benzoxazinas/uso terapêutico , Estudos Transversais , Ciclopropanos , Quimioterapia Combinada , Feminino , Infecções por HIV/sangue , Infecções por HIV/tratamento farmacológico , Humanos , Modelos Lineares , Pessoa de Meia-Idade , Nevirapina/sangue , Nevirapina/farmacocinética , Nevirapina/uso terapêutico , Oligopeptídeos/sangue , Oligopeptídeos/farmacocinética , Oligopeptídeos/uso terapêutico , Piridinas/sangue , Piridinas/farmacocinética , Piridinas/uso terapêutico , Fatores de Risco , Carga ViralRESUMO
BACKGROUND: Elevated intracranial pressure (eICP) is a serious medical emergency that requires prompt identification and monitoring. The current gold standards of eICP detection require patient transportation, radiation, and can be invasive. Ocular ultrasound has emerged as a rapid, non-invasive, bedside tool to measure correlates of eICP. This systematic review seeks to explore the utility of ultrasound detected optic disc elevation (ODE) as an ultrasonographic finding of eICP and to study its sensitivity and specificity as a marker of eICP. METHODS: This systematic review followed the preferred reporting items for systematic reviews and meta-analyses guidelines. We systematically searched PubMed, EMBASE, and Cochrane Central for English articles published before April 2023; yielding 1,919 total citations. After eliminating duplicates, and screening the records, we identified 29 articles that addressed ultrasonographically detected ODE. RESULTS: The 29 articles included a total of 1249 adult and pediatric participants. In patients with papilledema, the mean ODE ranged between 0.6 mm and 1.2 mm. Proposed cutoff values for ODE ranged between 0.3 mm and 1 mm. The majority of studies reported a sensitivity between 70 and 90%, and specificity ranged from 69 to 100%, with a majority of studies reporting a specificity of 100%. CONCLUSIONS: ODE and ultrasonographic characteristics of the optic disc may aid in differentiating papilledema from other conditions. Further research on ODE elevation and its correlation with other ultrasonographic signs is warranted as a means to increase the diagnostic accuracy of ultrasound in the setting of eICP.
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Objectives: Undergraduate ultrasound education is becoming increasingly important, but its expansion is limited by time, space and the availability of trained faculty. In order to validate an alternative and more accessible teaching model, our aim was to assess whether combining teleguidance and peer-assisted learning to teach ultrasound is as effective as traditional in-person methods. Methods: Peer instructors taught 47 second-year medical students ocular ultrasound via either teleguidance or traditional in-person methods. Proficiency was assessed using a multiple-choice knowledge test and objective structured clinical examination (OSCE). Confidence, overall experience, and experience with a peer instructor were measured using a 5-point Likert scale. Two one-sided t-tests were used to measure equivalency between the two groups. The null hypothesis that the two groups were not different was rejected when P < 0.05. Results: The teleguidance group performed as well as the traditional in-person group in terms of knowledge change, confidence change, OSCE time and OSCE score (p = 0.011, p = 0.006, p = 0.005 and = 0.004, respectively, indicating the two groups are statistically equivalent). The teleguidance group rated the experience highly overall (4.06/5), but less than the traditional group (4.47/5; P = 0.448, indicating statistical difference). Peer instruction was rated 4.35/5 overall. Conclusion: Peer-instructed teleguidance was equivalent to in-person instruction with respect to knowledge change, confidence gain and OSCE performance in basic ocular ultrasound.
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BACKGROUND: More severe influenza disease and poor vaccine immunogenicity in HIV-infected patients necessitate improved immunization strategies to maximize vaccine efficacy. METHODS: A phase III, randomized trial was conducted at 4 Canadian sites. Two dosing strategies (standard dose vs standard dose plus booster on day 21) were assessed in HIV patients aged 20 to 59 years during the H1N1(2009) pandemic. A single antigen, inactivated split adjuvanted (AS03(A)) influenza vaccine (Arepanrix) was utilized. Serum hemagglutination inhibition (HAI) titres were assessed at days 21 and 42 and at month 6. RESULTS: 150 participants received at least one injection. Baseline parameters were similar between groups: 83% male, 85% on HAART, median CD4 = 519 cells/mm(3), 84% with HIV RNA < 50 copies/mL. At day 21, seroprotection (HAI ≥1:40) was achieved in 80% (95% CI, 70-89) of participants. Seroconversion occurred in 74% (63-85). Seroprotection and seroconversion were further improved in those randomized to booster dosing: day 42, 94% (85-98) versus 73% (60-83) (P < .01) and 86% (75-93) versus 66% (5-77) (P = .01). Seroprotec-tion was retained in 40% (28-54) of recipients at month 6 with trends toward greater retention of immunity in booster recipients. CONCLUSION: High-level immunogenicity was achieved with a single dose of this adjuvanted vaccine. Immunogenicity was further improved with booster dosing. Use of this adjuvanted vaccine and booster represent an important approach to increasing immunogenicity in this vaccine hypo-responsive population.
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Imunização Secundária , Vírus da Influenza A Subtipo H1N1/imunologia , Vacinas contra Influenza/imunologia , Pandemias , Adulto , Contagem de Linfócito CD4 , Feminino , Testes de Inibição da Hemaglutinação , Humanos , Vacinas contra Influenza/efeitos adversos , Masculino , Pessoa de Meia-IdadeRESUMO
In Canada, universal and publicly funded hepatitis B immunization programs have been available since 1998 in all provinces and territories. This present study estimates the proportion of having vaccine-induced immunity to hepatitis B virus (HBV) infection and its associated determinants among street-involved youth aged at 15-24 years old in Canada using the data collected by the Enhanced Surveillance of Canadian Street Youth. Vaccine-induced immunity was identified by blood test results of anti-HBc negative and anti-HBs positive. Of the 4,035 participants included in this study, the overall proportion of those with vaccine-induced immunity to HBV was 51.7% during the study period compared to over 90% among the general adolescent population. The proportion of street-involved youth immunized with HBV vaccine increased from 34.7% in 1999 to 64.4% in 2005. Immunity was higher among females (aOR = 1.43, 1.17-1.75) and among those with a reported history of sexually transmitted infection (aOR = 1.30, 1.03-1.63). The proportion of youth with the immunity decreased as age increased (aOR = 0.78, 0.76-0.81, per year increase). Despite an overall increase in the proportion of Canadian street-involved youth with vaccine-induced immunity to HBV, the proportion was still significantly lower than that observed in the general adolescent population. This highlights the need to improve the access to basic health care and the immunization programs to HBV for street-involved youth through creative outreach programs and other multi-faceted approaches.
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Vacinas contra Hepatite B/uso terapêutico , Vírus da Hepatite B/imunologia , Hepatite B Crônica/prevenção & controle , Jovens em Situação de Rua , Adolescente , Canadá/epidemiologia , Estudos Transversais , Feminino , Anticorpos Anti-Hepatite B/isolamento & purificação , Hepatite B Crônica/epidemiologia , Humanos , Masculino , Vigilância da População , Infecções Sexualmente Transmissíveis/diagnóstico , Adulto JovemRESUMO
INTRODUCTION: Most trauma centers order abdominal and pelvic computed tomography (CT) as an automatically paired CT for adult blunt trauma evaluation. However, excessive CT utilization adds risks of excessive exposure to ionizing radiation, the need to work up incidental findings (leading to unnecessary and invasive tests), and greater costs. Examining a cohort of adult blunt trauma patients that received paired abdominal and pelvic (A/P) CT, we sought to determine the diagnostic yield of clinically significant injuries (CSI) in the following: 1) the abdomen alone; 2) the pelvis alone; 3) the lumbosacral spine alone; and 4) more than one of these anatomic regions concomitantly. METHODS: In this retrospective study, we reviewed the imaging and hospital course of a consecutive sample of blunt trauma activation patients older than 14 years of age who received paired A/P CT during their blunt trauma assessments at an urban Level I trauma center from April through October 2014. Categorization of CSI was determined according to an a priori, expert panel-derived classification scheme. RESULTS: The median age of the 689 patients who had A/P CT was 48 years old; 68.1% were male; 64.0% were admitted, and hospital mortality was 3.6%. CSI yields were as follows: abdomen 2.2% (95% confidence interval [CI] [1.3-3.6%]); pelvis 2.9% (95% CI [1.9-4.4%]); lumbosacral spine 0.6% (95% CI [0.2-1.5%]); both abdomen and pelvis 0.3% (95% CI [0.1-1.1%]); both the abdomen and lumbosacral spine 0.6% (0.2-1.5%); both the pelvis and lumbosacral spine 0.1% (0.0-0.8%); all three regions - abdomen, pelvis and lumbosacral spine - 0.1% (0.0-0.8%). CONCLUSION: Automatic pairing of A/P CT has very low diagnostic yield for CSI in both the abdomen and pelvis. These data suggest a role for selective CT imaging protocols that image these regions individually instead of automatically as a pair.
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Traumatismos Abdominais/diagnóstico por imagem , Região Lombossacral/lesões , Pelve/lesões , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Centros de Traumatologia , Ferimentos não Penetrantes/diagnóstico , Feminino , Humanos , Região Lombossacral/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Pelve/diagnóstico por imagem , Estudos RetrospectivosRESUMO
BACKGROUND: Petrous face meningiomas (PFMs) are challenging tumors because of their proximity to the cranial nerves, brainstem, and critical vasculature. The objective of this study is to present surgical outcomes and support an anatomic classification for PFM based on clinical presentation. METHODS: A retrospective chart review was performed, and 51 PFMs were identified. Tumors were classified by location along the petrous face into anterior, middle, and posterior. Presentation and outcomes were analyzed with logistic regression. RESULTS: The median follow-up was 31.6 months. Tumors were World Health Organization grade I (n = 50), with 1 World Health Organization grade II tumor. Location was anterior (22%), middle (14%), posterior (53%), and overlapping (12%). Median tumor diameter was 3.0 cm (range, 0.8-6.2 cm). Anterior location was associated with facial pain/numbness on presentation (P < 0.0001), middle location with hearing loss/vestibular dysfunction (P = 0.0035), and posterior with hydrocephalus (P = 0.0190), headache (P = 0.0039), and vertigo (P = 0.0265). Extent of resection was gross total (63%), near total (14%), and subtotal (25%). The observed radiographic recurrence rate was 15%. Mean progression-free survival after diagnosis was 9.1 years with 2-year, 5-year, and 10-year progression-free survival of 91.8%, 78.6%, and 62.9%, respectively. The complication rate was 27%. Age, location, and approach were not associated with complications. CONCLUSIONS: PFMs present with distinct clinical syndromes based on their location along the petrous face: anterior with trigeminal symptoms, middle with auditory/vestibular symptoms, and posterior with symptoms of mass effect/hydrocephalous. Surgical resection is associated with excellent long-term survival and a low rate of recurrence, which can be managed with radiotherapy.
Assuntos
Nervos Cranianos/cirurgia , Neoplasias Meníngeas/classificação , Neoplasias Meníngeas/cirurgia , Meningioma/classificação , Meningioma/cirurgia , Osso Petroso/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Nervos Cranianos/diagnóstico por imagem , Neoplasias Faciais/classificação , Neoplasias Faciais/diagnóstico por imagem , Neoplasias Faciais/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Neoplasias Meníngeas/diagnóstico por imagem , Meningioma/diagnóstico por imagem , Pessoa de Meia-Idade , Osso Petroso/diagnóstico por imagem , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: We did a randomised, double-blind, controlled clinical trial to prospectively assess whether use of combination antibiotic susceptibility testing improved clinical outcomes in patients with acute pulmonary exacerbations of cystic fibrosis who were infected with multiresistant bacteria. METHODS: 251 patients with cystic fibrosis who were chronically infected with multiresistant gram negative bacteria gave sputum at 3-month intervals for conventional culture and sensitivity tests and for combination antibiotic susceptibility tests using multiple combination bactericidal antibiotic testing (MCBT). Patients who developed an exacerbation of pulmonary disease were randomised to receive a 14-day course of any two blinded intravenous antibiotics chosen on the basis of either results from conventional sputum culture and sensitivity testing or the result of MCBT. The primary outcome was time from randomisation until the patient's next pulmonary exacerbation. Analysis was by intention-to-treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN60187870. FINDINGS: 132 patients had a pulmonary exacerbation and were randomised during the 4.5-year study period. The time to next pulmonary exacerbation was not prolonged in the MCBT-treated group (hazard ratio 0.86 in favour of the conventionally-treated group, 95% CI 0.60-1.23, p=0.40). There was no difference between the groups in treatment failure rate. After 14 days of intravenous antibiotic therapy, changes in lung function, dyspnoea, and sputum bacterial density were similar in both groups. INTERPRETATION: Antibiotic therapy directed by combination antibiotic susceptibility testing did not result in better clinical and bacteriological outcomes compared with therapy directed by standard culture and sensitivity techniques. The non-bactericidal effects of antibiotic therapy might play an important part in determining improvement in patients with cystic fibrosis pulmonary exacerbations.
Assuntos
Antibacterianos , Fibrose Cística/microbiologia , Farmacorresistência Bacteriana Múltipla , Testes de Sensibilidade Microbiana , Infecções Respiratórias/microbiologia , Doença Aguda , Adulto , Doença Crônica , Fibrose Cística/complicações , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Humanos , Masculino , Infecções Respiratórias/complicações , Infecções Respiratórias/tratamento farmacológico , Escarro/microbiologiaRESUMO
Adaptive immunity in vertebrates can confer increased resistance against invading pathogens upon re-infection. But how specific parasite genotypes affect the temporal transition from innate to adaptive immunity under continual exposure to parasites is poorly understood. Here, we investigated the effects of homologous and heterologous exposures of genetically distinct parasite lineages of the eye fluke Diplostomum pseudospathaceum on gene expression patterns of adaptive immunity in sticklebacks (Gasterosteus aculeatus). Observable differences in gene expression were largely attributable to final exposures while there was no transcription pattern characteristic for a general response to repeated infections with D. pseudospathaceum. None of the final exposure treatments was able to erase the distinct expression patterns resulting from a heterologous pre-exposed fish. Interestingly, heterologous final exposures showed similarities between different treatment groups subjected to homologous pre-exposure. The observed pattern was supported by parasite infection rates and suggests that host immunization was optimized towards an adaptive immune response that favored effectiveness against parasite diversity over specificity.
Assuntos
Imunidade Adaptativa/imunologia , Doenças dos Peixes/imunologia , Smegmamorpha/imunologia , Smegmamorpha/parasitologia , Infecções por Trematódeos/imunologia , Sequência de Aminoácidos , Animais , Sequência de Bases , Genótipo , Interações Hospedeiro-Parasita/imunologia , Dados de Sequência Molecular , Reação em Cadeia da Polimerase , Transcriptoma , Trematódeos/genética , Infecções por Trematódeos/genéticaRESUMO
Immune systems of vertebrates are much more diverse than previously thought, in particular at the base of the vertebrate clade. RNA-seq was used to describe in detail the transcriptomic response of stickleback hosts to infection by two helminth parasites, the trematode Diplostomum pseudospathaceum (2 genotypes plus a genotype mix) and the cestode Schistocephalus solidus. Based on a global transcription profiling, we present immune genes that are active during chronic or multiple repeated infection. We found that the transcription profiles of D. pseudospathaceum genotypes were as divergent as those of the two parasite species. When comparing the host immune response, only 5 immune genes were consistently upregulated upon infection by both species. These genes indicated a role for enhanced toll like receptor (TLR) activity (CTSK, CYP27B1) and an associated positive regulation of macrophages (CYP27B1, THBS1) for general helminth defense. We interpret the largely differentiated gene expression response among parasite species as general redundancy of the vertebrate immune system, which was also visible in genotype-specific responses among the different D. pseudospathaceum infections. The present study provides the first evidence that IL4-mediated activation of T-helper lymphocyte cells is also important in anti-helminthic immune responses of teleost fish.
Assuntos
Infecções por Cestoides/veterinária , Doenças dos Peixes/parasitologia , Smegmamorpha/parasitologia , Transcriptoma , Infecções por Trematódeos/veterinária , Animais , Cestoides/classificação , Infecções por Cestoides/imunologia , Infecções por Cestoides/metabolismo , Doenças dos Peixes/imunologia , Doenças dos Peixes/metabolismo , Regulação da Expressão Gênica/imunologia , Trematódeos , Infecções por Trematódeos/imunologia , Infecções por Trematódeos/metabolismoRESUMO
Precision or personalized medicine through clinical genome and exome sequencing has been described by some as a revolution that could transform healthcare delivery, yet it is currently used in only a small fraction of patients, principally for the diagnosis of suspected Mendelian conditions and for targeting cancer treatments. Given the burden of illness in our society, it is of interest to ask how clinical genome and exome sequencing can be constructively integrated more broadly into the routine practice of medicine for the betterment of public health. In November 2014, 46 experts from academia, industry, policy and patient advocacy gathered in a conference sponsored by Illumina, Inc. to discuss this question, share viewpoints and propose recommendations. This perspective summarizes that work and identifies some of the obstacles and opportunities that must be considered in translating advances in genomics more widely into the practice of medicine.
Assuntos
Atenção à Saúde/organização & administração , Genoma Humano , Genômica/métodos , Medicina de Precisão/tendências , Atenção à Saúde/métodos , Testes Genéticos , Genômica/instrumentação , Sequenciamento de Nucleotídeos em Larga Escala , Humanos , Kit de Reagentes para DiagnósticoRESUMO
The Merlin Immediate HIV-1 and -2 Test (Merlin point-of-care [POC] test; Merlin Biomedical & Pharmaceutical) is a nitrocellulose membrane flow immunoassay performed at the POC with the use of blood obtained from a fingerprick. The results of this test were compared with those of enzyme immunoassay (EIA) performed on venous blood samples in the laboratory. Positive results of both tests were confirmed by a Western blot (WB). The study included 553 adults with known HIV (human immunodeficiency virus) seropositivity (all of whom had positive Merlin POC test results) and 2659 adults with unknown HIV serostatus (20 of whom had positive EIA/WB results; 19 of the 20 also had positive Merlin-POC test results). The sensitivity of the Merlin POC test was 95.0% for patients with an unknown HIV serostatus and 99.83% for those with a positive serostatus. For previously untested subjects, the test's specificity and positive predictive value were 100%, its negative predictive value was 99.96%, and its overall accuracy was 99.96%. The Merlin POC test is highly accurate for the detection of HIV antibodies.