Practical approach to a patient with fever who travelled to the tropics.

By 2030, an estimated 2 billion international tourist trips are expected annually worldwide, with citizens of Poland as important contributors. Illness rates among returnees from developing regions range between 43% and 79%. Properly diagnosing fever in these travelers is vital due to potentially serious implications. After visiting tropical and subtropical zones, the main health complaints are diarrhea, fever, and skin lesions. A reliable diagnosis begins with taking a comprehensive travel history and identifying potential risks. In travelers returning from sub­Saharan Africa, malaria caused by Plasmodium falciparum is the main cause of fever, affecting 50 in every 1000 cases. Among returnees from Southeast Asia, dengue is dominant, occurring in 50-60 per 1000 cases, and its prevalence rises significantly nowadays. Other significant diseases include chikungunya, Zika, typhoid fever, amebic liver abscess, and occasionally viral hemorrhagic fevers. SARS­CoV­2 and influenza viruses are crucial pathogens as well. An in­depth assessment of the travel history, combined with knowledge on tropical diseases, are key to the diagnostic process, and algorithms may be helpful in selecting appropriate tests and treatment methods.

Cutaneous Larva Migrans as a frequent problem in travellers.

Dermatological disorders are among the most common complaints of patients seeking medical assistance after returning from trips to tropical countries. Among exotic dermatoses, one of the frequently encountered diagnoses is Cutaneous Larva Migrans (CLM), primarily caused by the nematodes Ancylostoma braziliense and A. caninum. Cats and dogs, which serve as the definitive hosts for these nematodes, excrete with their stool parasite eggs into the environment, where they transform into larvae. Human infection occurs through the invasive form of the larvae, which penetrate the skin, causing itching and the characteristic serpiginous, slightly raised, and enlarging lesion at the site of invasion. Diagnosis is made based on the highly characteristic clinical presentation, although in non-endemic countries, diagnostic errors and delays in initiating effective causal treatment are relatively common. Effective therapy includes oral albendazole and ivermectin. Prevention of CLM involves avoiding skin contact with potentially contaminated soil by wearing shoes and using towels and mats on the beach. Due to the high interest in travel and the risk of importing exotic diseases, it is important to promote knowledge of tropical medicine among healthcare professionals as well as the travellers.

Lipids as a key element of insect defense systems.

The relationship between insect pathogenic fungi and their insect hosts is a classic example of a co-evolutionary arms race between pathogen and target host: parasites evolve towards mechanisms that increase their advantage over the host, and the host increasingly strengthens its defenses. The present review summarizes the literature data describing the direct and indirect role of lipids as an important defense mechanism during fungal infection. Insect defense mechanisms comprise anatomical and physiological barriers, and cellular and humoral response mechanisms. The entomopathogenic fungi have the unique ability to digest the insect cuticle by producing hydrolytic enzymes with chitin-, lipo- and proteolytic activity; besides the oral tract, cuticle pays the way for fungal entry within the host. The key factor in insect resistance to fungal infection is the presence of certain types of lipids (free fatty acids, waxes or hydrocarbons) which can promote or inhibit fungal attachment to cuticle, and might also have antifungal activity. Lipids are considered as an important source of energy, and as triglycerides are stored in the fat body, a structure analogous to the liver and adipose tissue in vertebrates. In addition, the fat body plays a key role in innate humoral immunity by producing a range of bactericidal proteins and polypeptides, one of which is lysozyme. Energy derived from lipid metabolism is used by hemocytes to migrate to the site of fungal infection, and for phagocytosis, nodulation and encapsulation. One polyunsaturated fatty acid, arachidonic acid, is used in the synthesis of eicosanoids, which play several crucial roles in insect physiology and immunology. Apolipoprotein III is important compound with antifungal activity, which can modulate insect cellular response and is considered as important signal molecule.

Additive Manufacturing of Oral Tablets: Technologies, Materials and Printed Tablets.

Additive manufacturing (AM), also known as three-dimensional (3D) printing, enables fabrication of custom-designed and personalized 3D constructs with high complexity in shape and composition. AM has a strong potential to fabricate oral tablets with enhanced customization and complexity as compared to tablets manufactured using conventional approaches. Despite these advantages, AM has not yet become the mainstream manufacturing approach for fabrication of oral solid dosage forms mainly due to limitations of AM technologies and lack of diverse printable drug formulations. In this review, AM of oral tablets are summarized with respect to AM technology. A detailed review of AM methods and materials used for the AM of oral tablets is presented. This article also reviews the challenges in AM of pharmaceutical formulations and potential strategies to overcome these challenges.

Predictive Value of Bleb Vascularity after Mitomycin C Augmented Trabeculectomy.

BACKGROUND: To evaluate the relationship between bleb vascularity and surgical outcome one year after mitomycin C (MMC) augmented trabeculectomy. METHODS: This was a prospective study of 51 eyes of 44 patients after MMC-augmented primary trabeculectomy with follow-up of 12 months. The total vessel area of a bleb was measured with ImageJ software on color photographs of the bleb on day 1 and 14, then months 1, 3, 6 and 12 after trabeculectomy. Blebs were classified clinically as successful (intraocular pressure (IOP) ≤ 18 mmHg and a >30% reduction in IOP without antiglaucoma medications or additional surgical interventions) or failed. Linear regression analysis was performed to determine the correlation of bleb vascularity with IOP and outcome. RESULTS: At 1 year, 40 eyes (78.4%) were classified as successful and 11 eyes (21.6%) as failed. The mean bleb vascularity at 1, 3 and 12 months after surgery was significantly higher in failed blebs (16.31% vs. 13.01%, p = 0.005, 14.93% vs. 10.15%, p = 0.001, 8.99% vs. 6.37%, p = 0.011, respectively). There were no significant differences in mean bleb vascularity at 1 and 14 days postoperatively in successful and failed blebs. The results revealed a significant association between vessel area at 1 and 3 months after trabeculectomy with IOP at 6 months postoperatively (p = 0.005 and p = 0.009, respectively). CONCLUSIONS: In this prospective study, we demonstrated a strong relationship between bleb vascularity and the surgical outcomes of trabeculectomy. Vascularity of the filtering bleb during early postoperative period was not correlated with IOP or success of trabeculectomy at one year. Increased bleb vascularity 1, 3 and 12 months after trabeculectomy appears to predict surgical failure at 1 year after trabeculectomy.

Selected arboviral diseases imported to Poland - current state of knowledge and perspectives for research.

INTRODUCTION: Arthropod-borne viruses are important causes of human morbidity worldwide. However, the available literatur and the epidemiological data concerning the importation to Poland of globally emerging arboviral infections, such as DENV, CHIKV, WNV, or ZIKV, are scarce. Only few seroepidemiologic studies concerning WNV in animals or humans in Poland have been published. OBJECTIVE: The aim of this review paper is to summarize and present the current state of knowledge and the perspectives for research concerning the importation and the risk posed by the introduction to Poland of the four above-mentioned arboviral diseases. CURRENT STATE OF KNOWLEDGE: Climate change may facilitate the northward expansion of both the vectors for diseases previously unseen in Europe, as well as of the viruses themselves, resulting in autochthonous cases of diseases previously exclusively imported. Little is known about the importation of arboviral diseases to Poland because of the frequently asymptomatic or self-limiting course of the disease, lack of epidemiologic studies or effective disease reporting, as well as inadequate access to diagnostic methods. CONCLUSIONS: Further epidemiologic studies in Polish travellers are necessary in order to prevent importation or introduction of the above-mentioned viruses, and to act against potential problems related to blood transfusion or organ transplantation from infected donors.

Malaria vaccine for travellers - where are we now?

The authors present a short summary of the current state of malaria vaccine development and the per- spectives for the availability of a malaria vaccines for travellers from non-endemic countries. There is currently no commercially available malaria vaccine for travellers. The efficacy of the RTS,S/AS01 vaccine is limited and differs dramatically from the effects of other vaccines administered in travel medicine. In the current recommendations, the use of repellents is deemed the most important measure to prevent malaria infection, and in the high-risk destinations, chemoprophylaxis is strongly advised. Many questions in malaria vaccinology remain unanswered.

Imported cutaneous leishmaniasis: a 13-year experience of a Polish tertiary center.

INTRODUCTION: Leishmaniasis is a vector-borne infection endemic in 98 countries. Its cutaneous form (CL) causes skin lesions on exposed parts of the body and may lead to scarring. The numbers of imported cases of CL are increasing in Europe but the incidence of CL importation in Poland is unknown. MATERIAL AND METHODS: A list of all patients diagnosed with CL at the Department in the years 2005-2017 was obtained. The study presents their data including age, sex, areas visited, purpose of travel, time from the onset of symptoms to correct diagnosis, appearance of lesions, results of impression smears and PCR, and superinfection, if detected, as well as treatment methods and their outcomes. RESULTS: Altogether, 14 cases of cutaneous leishmaniasis were identified. The study demonstrates an increase in the number of cases of imported CL at our center over the last 5 years. The time to correct diagnosis was long in spite of the fact that the lesions had usually an appearance typical of CL. CONCLUSIONS: Intensified education of physicians and travelers, as well as improvement in the access to travel medicine services and to the diagnosis and treatment methods appropriate for CL, are needed in our country. In our opinion, surveillance of leishmaniasis should be introduced in Poland.

Chronic symptoms persisting after travel-related infections.

The authors present the current state of knowledge about the long term sequelae of the common travel-related infections associated with immunological dysregulation. Travellers' diarrhoea, chikungunya and dengue are common in travellers and protracted manifestations such as post-infectious irritable bowel syndrome (travellers' diarrhoea), arthritis (chikungunya) or post-dengue syndrome may be more prevalent than previously thought. Attention should be paid to active prevention of the infections during travel, especially when an effective treatment against long-term sequelae has not been established. Further studies should be designed in order to determine the interactions between the host, the environment and the pathogens, as well as to identify the prognostic factors for developing long-term manifestations after infections in a large group of travellers.

Cholera - the new strike of an old foe.

Cholera is an acute bacterial gastrointestinal infection caused by ingestion of water or food containing the pathogen Vibrio cholerae. The incubation period can be very short and it takes between several hours and 5 days. During the 19th century, cholera was spreading from India across the world. Its original reservoir was located in the Ganges delta. So far, there have been six epidemics of cholera; the current outbreak is the seventh. It started in Asia, attacked Africa and then the Americas. Cholera causes thousands of illnesses and deaths annually, mostly in South Asia and Sub-Saharan Africa. The current outbreak began in Yemen in October 2016, it peaked in December with subsequent decline, then the epidemic has re-erupted in April 2017 and it still continues. It is currently the largest outbreak in the world, with 5000 new infections a day (as of August 19th, 2017 the number of cholera cases stands at 527,000 with 1997 deaths). The most common symptoms of the illness are diarrhoea, dehydration, vomiting, and abdominal cramps. Case-fatality rate is lower than 1%, if rehydration treatment is prescribed rapidly, but it can exceed 70% in patients not treated properly. Aggressive and rapid fluid repletion is the basis of treatment for cholera. In many cases, rehydration therapy, given orally or parenterally, is enough to rescue infected patients. Antibiotics, mainly fluoroquinolones, tetracyclines, and macrolides are an adjunctive therapy for patients with moderate to severe fluid loss.

Evaluation of knowledge and use of the malaria prevention measures among the patients of the Department of Tropical and Parasitic Diseases University Center of Maritime and Tropical Medicine, Gdynia, based on a questionnaire performed in the years 2012-20

INTRODUCTION: Every year, approximately 125 million travelers visit areas where malaria prevails, located in over 100 countries. Over 10,000 of them suffer from malaria annually. Visitors to these areas may protect themselves against infection by using chemoprophylaxis, insect repellents, appropriate clothing, sleeping in airconditioned and well-screened quarters or using mosquito nets impregnated with insecticides. AIM OF THE STUDY: The aim of this study was to gather and analyze the data about knowledge and usage of pharmacological and non-pharmacological malaria prevention methods among the patients of the University Centre for Maritime and Tropical Medicine (UCMMiT), Gdynia, Poland, in 2012-2013. MATERIAL AND METHODS: A survey was conducted among 245 patients hospitalized in the Department of Tropical and Parasitic Diseases, UCMMiT in Gdynia, Poland in 2012 - 2013. The only criterion for inclusion was a sojourn and consent for participation in the study. The questionnaire included questions concerning mainly the use of chemoprophylaxis, opinion on the medication used for prophylaxis, side effects during its usage, the non-pharmacological prevention methods used against insect bites. RESULTS: Due to travel destination, malaria chemoprophylaxis should have been recommended for 73 (30%) individuals prior to the travel. It should not have been recommended for the group of 129 patients reporting long-term sojourns (over a year) and for 43 persons (17%) due to their travel to non-endemic countries. In fact, chemoprophylaxis in the "recommended" group was used by 32 persons which constituted 44%, while in the "long sojourn" group prophylaxis was used by 7 persons and in the "not recommended group" by 1 person. The number of people who reported proper use of chemoprophylaxis (an appropriate drug and mode of usage) amounted to 26 (36%) in the "recommended" group. Among bite prevention methods, usage of window mosquito nets was reported by 154 people (63%), bed mosquitonets by 39 (16%), insect repellents by 52 (21%) and insecticides by 52 (21%) patients. Adverse effects associated with chemoprophylaxis were reported by 10 persons (26%) but none of them stopped taking the medication. CONCLUSIONS: In spite of the availability of information on the Internet and the access to pre-travel medical counseling, the knowledge of correct prophylaxis against malaria among the people traveling to tropical countries is still unsatisfactory, leading to increased risk of Plasmodium infections. Better understanding of prophylaxis rules among travelers may increase usage of non-pharmacological methods and highlight the factors affecting usage of prevention methods.

A case of acalculous cholecystitis in the course of dengue fever in a traveller returned from Brazil.

BACKGROUND: Dengue is the second cause of fever after malaria in travellers returning from the tropics. The infection may be asymptomatic or it may manifest itself with fever only, some patients, however, may develop haemorrhagic symptoms and shock. MATERIALS AND METHODS: A 58-year-old woman came to the University Centre of Tropical Medicine in Gdynia after returning from a tourist journey to Brazil because of fever up to 39°C and malaise. She had lived in South America many years and then moved to Europe 3 years before hospitalisation. On admission physical examination revealed fever, dry mucosa, moderate hypotension and tachycardia. In the laboratory test results, leukopoenia, thrombocytopoenia and elevated transaminases were observed. On the second day of the hospitalisation, the patient reported epigastric pain, clinical examination revealed tenderness of the abdomen and macular rash on the skin of the trunk and thighs. The ultrasonography revealed an enlarged gallbladder with thickened walls, with hypoechogenic area surrounding it, a dilated common biliary duct of heterogenic echo, and some free fluid in the peritoneal cavity. An exploratory laparotomy was performed after 24 h because of the persisting strong abdominal pain and high fever. Intraoperatively, enlarged mesenteric lymph nodes were found, with no symptoms of gallbladder pathology. The postoperative course was uncomplicated and the positive result of immunochromatographic assay for dengue was obtained. RESULTS: The acalculous cholecystitis has been described in the course of various diseases and conditions. The typical symptoms include pain in the right hypochondriac region, fever, positive Murphy's sign, and abnormal liver function tests, which were observed in the presented case. Cholecystectomy is not usually indicated in the course of dengue (typically a self-limiting disease) due to a high risk of bleeding. CONCLUSIONS: The case provides a rationale for the inclusion of acalculous cholecystitis in the differential diagnosis in patients with abdominal pain returning from dengue endemic areas.

Imported Malaria in the Material of the Institute of Maritime and Tropical Medicine: A Review of 82 Patients in the Years 2002-2014.

Malaria is, along with tuberculosis and HIV/AIDS, one of the three most dangerous infectious diseases in the world. In the absence of native cases since 1963, malaria has remained in Poland an exclusively imported disease, mainly occurring in people travelling to tropical and subtropical areas for professional reasons. The aim of this study was the epidemiological and clinical analysis of 82 patients admitted to the University Center for Maritime and Tropical Medicine (UCMTM), Gdynia, Poland, with a diagnosis of malaria between 2002 and 2014. The "typical" patient with malaria was male, middle-aged, returned from Africa within the preceding 4 weeks, had not used appropriate chemoprophylaxis, and had not applied nonpharmacological methods of prophylaxis, except for window insect screens. P. falciparum was the most frequent species. The most common symptoms included fever, shivers and intensive sweating, thrombocytopenia, elevated creatinine, LDH, D-dimers and CRP, hepatomegaly, and splenomegaly. Within the analyzed group, severe malaria according to WHO standards was diagnosed in 20.7% of patients. Our report presents analysis of the largest series of patients treated for imported malaria in Poland.

Investigations on the occurrence of Plasmodium knowlesi in travellers returning from the endemic areas of simian malaria.

Malaria remains an important public health issue all over the world. Among 5 Plasmodium species invasive to humans, Plasmodium knowlesi has been identified most recently. It is sometimes difficult to differentiate this species from P. malariae with the use of microscopic examination. However, P. knowlesi infection may be associated with rapidly increasing parasitaemia and severe clinical course with the risk of death. Samples from Polish travellers returning from areas where simian malaria is endemic were examined with the use of polymerase chain reaction (PCR). The small subunit of ribosomal RNA (SSU rRNA) genes was subjected to analysis using nested PCR reaction. No positive results of P. knowlesi were obtained. Due to morphological similarities to P. malariae, potentially severe clinical course of infection and P. knowlesi endemic regions being a common tourist destination, diagnostic and clinical vigilance is necessary, including molecular methods use for precise parasite identification.

Different serotypes of dengue virus (DENV) imported by Polish travellers from dengue endemic areas to Poland.

BACKGROUND: Dengue viruses are the most widespread arboviruses (transmitted mainly by Aedes aegypti and Ae. albopictus mosquitoes), which have shown an unexpected geographic expansion. There are four dengue virus serotypes: DENV-1, DENV-2, DENV-3, and DENV-4. Subsequent infections increase the risk of developing severe dengue fever. MATERIALS AND METHODS: Samples from travellers returning from the endemic area of dengue fever were examined with the reverse transcription-polymerase chain reaction method. Primers amplified 743 bp fragment of the NS5 and 3'UTR genomic region of mosquito-borne flaviviruses of JEV group were used. RESULTS: The sequences from the 10 examined patients were compared to available DENV sequences in GenBank database and the basic local alignment search tool (BLAST) results confirmed that the infective virus was DENV-1 (6 patients), DENV-2 (2 patients) and DENV-3 (2 patients). CONCLUSIONS: For the first time in Poland, dengue virus serotypes were determined in travellers returning from dengue-endemic areas.

From Exhaustion to Disengagement via Self-Efficacy Change: Findings from Two Longitudinal Studies among Human Services Workers.

This longitudinal research examined the relationship direction between burnout components (exhaustion and disengagement) within the context of personal resources measured by self-efficacy and social support. In line with the conservation of resources theory we hypothesized that exhaustion may trigger a spiral loss of personal resources where self-efficacy declines and subsequently, social support also declines and in turn predict disengagement. Participants in Study 1 were mental healthcare providers (N = 135) working with U.S. military personnel suffering from trauma. Participants in Study 2 were healthcare providers, social workers, and other human services professionals (N = 193) providing various types of services for civilian trauma survivors in Poland. Baseline and 6-month follow-up measurements included burnout components, burnout self-efficacy and perceived social support. The path analysis showed consistent results for both longitudinal studies; exhaustion measured at Time 1 led to disengagement at Time 2, after controlling for baseline disengagement levels. Across Study 1 and Study 2 these associations were mediated by self-efficacy change: Higher exhaustion led to greater decline in self-efficacy which in turn explained higher disengagement at the follow-up. Social support, however, did not mediate between self-efficacy and disengagement. These mediating effects were invariant across Studies 1 and 2, although the mean levels of burnout and personal resources differed significantly. The results contribute to a discussion on the internal structure of job burnout and a broader understanding of the associations between exhaustion and disengagement that may be explained by the underlying mechanism of change in self-efficacy.

An attempt to estimate the minimal number of Poles infected and treated for malaria in Poland and abroad.

BACKGROUND: Malaria is one of the three most dangerous infectious diseases in the world. According to official statistics, there are a few dozen cases in Poland annually while the number of Poles treated abroad or self-treating remains unknown. Poland has been declared to be malaria-free since 1963 and nowadays all cases are imported. The aim of the study is to determine the minimal number of malaria cases in Poles at home and abroad in the last decade. MATERIALS AND METHODS: The medical records of 4,710 patients tested for malaria in the Department of Tropical Parasitology in the years 2003-2012 were analysed. Two spreadsheets were created, which only included people with a history of malaria diagnosed in the reference centre where indirect immunofluorescent-antibody assay (IFA) for Plasmodium falciparum antigen proved positive. The minimum number of Poles who have had malaria at home and abroad was calculated on the basis of positive IFA results; the rate of all treated malaria patients in Poland in relation to those treated in the reference centre and the actual number of Poles with malaria diagnosed at home was calculated. RESULTS: A group of 376 people with positive serologic tests results in indirect immunofluorescent antibody assay with titre ≥ 1:20 were received, including 227 patients with positive serologic results with titre ≥ 1:80. The rate of the overall number of malaria cases in Poland compared to the number of malaria cases in the University Centre for Maritime and Tropical Medicine Hospital was determined as 3.47:1. It was demonstrated that every year at least 174 to 211 Poles staying abroad may suffer from malaria. CONCLUSIONS: This is the first attempt to estimate the minimal number of Poles infected and treated for malaria in Poland and abroad. The estimated number is 8-10 times greater than the number of registered cases in Poland.