Pneumocystis jiroveci Pneumonia: A Review of Management in Human Immunodeficiency Virus (HIV) and Non-HIV Immunocompromised Patients.

Pneumocystis jirovecii pneumonia is an opportunistic fungal infection that was mainly associated with pneumonia in patients with advanced human immunodeficiency virus (HIV) disease. There has been a decline in Pneumocystis jirovecii pneumonia incidence in HIV since the introduction of antiretroviral medications. However, its incidence is increasing in non-HIV immunocompromised patients including those with solid organ transplantation, hematopoietic stem cell transplantation, solid organ tumors, autoimmune deficiencies, and primary immunodeficiency disorders. We aim to review and summarize the etiology, epidemiology, clinical presentation, diagnosis, and management of Pneumocystis jirovecii pneumonia in HIV, and non-HIV patients. HIV patients usually have mild-to-severe symptoms, while non-HIV patients present with a rapidly progressing disease. Induced sputum or bronchoalveolar lavage fluid can be used to make a definitive diagnosis of Pneumocystis jirovecii pneumonia. Trimethoprim-sulfamethoxazole is considered to be the first-line drug for treatment and has proven to be highly effective for Pneumocystis jirovecii pneumonia prophylaxis in both HIV and non-HIV patients. Pentamidine, atovaquone, clindamycin, and primaquine are used as second-line agents. While several diagnostic tests, treatments, and prophylactic regimes are available at our disposal, there is need for more research to prevent and manage this disease more effectively.

Trends of Vancomycin-Resistant Enterococcus Infections in Cancer Patients.

Objective Vancomycin-resistant Enterococcus (VRE) is an important cause of infection in immunocompromised populations. In Pakistan, very limited data are available regarding Enterococcus infection and its outcomes. We conducted this study to evaluate the trends including risk factors, treatment options, and outcomes of infections due to vancomycin-resistant enterococci in cancer patients in Pakistan. Methods We conducted a retrospective observational study. We extracted data from medical records of our center over a period of seven years. All admitted cancer patients with any vancomycin-resistant Enterococcus positive culture were included. The following parameters were evaluated: age, gender, type of cancer, febrile neutropenia, prior antibiotics, admission, comorbidities, system-wise infections (including bacteremia, catheter-related infection, pneumonia, urinary tract infections, intra-abdominal infection, bone and joint infections, skin and skin structure infections), intensive care unit admission, and 30-day all-cause mortality. Frequencies of infections, mortality, and drug susceptibility were evaluated over the course of seven years. Results Risk factors for enterococcal infection included prior exposure of piperacillin/tazobactam (n=209, 86.7%), meropenem (n=132, 54.8%), vancomycin (n=126, 52.3%), metronidazole (n=67, 27.8%), prior admission for more than 48 hours (n=198, 82.2%), and comorbidities (n=76, 31.5%), with acute kidney injury being most common (n=72, 95%) followed by diabetes mellitus (n=70, 92.1%). Precursor B cell acute lymphoblastic leukemia (pre-B ALL) was the most common malignancy in which infection occurred (n=54, 38.3%). Among patients who developed infection, 46% (n=111) had febrile neutropenia. Enterococcus species caused infection in 61% (n=147) and Enterococcus faecium in 39% (n=94). Bacteremia occurred in 45.2% (n=109) patients followed by urinary tract and intra-abdominal infection; 45.6% (n=110) patients were admitted to ICU, and 30-day all-cause mortality was 44.8% (n=108). Linezolid sensitivity was 100%. The total number of enterococci infections decreased over seven years. Frequency of E. species infection, bacteremia, intra-abdominal, skin-related infections, and recurrent infection also decreased, but the frequency of E. facium infections, ICU admission, and 30-day all-cause mortality was increased. Conclusion VRE infections have become less frequent but more severe in recent years with increase in mortality. Prior use of antibiotics (including piperacillin/tazobactam, vancomycin, carbapenems, and metronidazole), diagnosis of hematological malignancy, febrile neutropenia, diabetes mellitus, and renal failure are the risk factors for VRE infection. Bacteremia was the most common infection with high mortality rate. All strains remain sensitive to linezolid. Patients with these risk factors should be worked up for VRE and can be treated with linezolid empirically.

Dynamic analysis of the mathematical model of COVID-19 with demographic effects.

The coronavirus is currently extremely contagious for humankind, which is a zoonotic tropical disease. The pandemic is the largest in history, affecting almost the whole world. What makes the condition the worst of all is no specific effective treatment available. In this article, we present an extended and modified form of SIR and SEIR model, respectively. We begin by investigating a simple mathematical model that describes the pandemic. Then we apply different safety measures to control the pandemic situation. The mathematical model with and without control is solved by using homotopy perturbation method. Obtained solutions have been presented graphically. Finally, we develop another mathematical model, including quarantine and hospitalization.

An empirical study exploring the determinants of stress among medical healthcare professionals.

BACKGROUND: Medical profession is considered as one of the stressful professions. Work related stress level among the general working population is around 18% while the stress level among the healthcare practitioners is around 28%. Multiple stressors contribute to the stress of doctors resulting in negative consequences. OBJECTIVE: The objective of the current study was to determine, categorize and to rank the existing stressors according to their significance for medical healthcare professionals in Pakistan. METHOD: A self-administered questionnaire was used to collect data from 327 doctors. 47.2% were males while 52.8% were females. A structured questionnaire was developed and convenience sampling technique was applied to collect the data from the different positions of healthcare professionals. Exploratory factor analysis (EFA) was performed to categorize and to analyse the underlying structure of stressors. Finally, the stressors were ranked according to their significance. RESULTS: Appropriateness of factor model was judged through Kaiser, Meyer and Olkin (KMO) index which was 0.905, and by Bartlett's Test of Sphericity which resulted significant (Approx. Chi- Square= 1111.529, Df =136, Sig.=0.000). Seventeen stressors were converted into four categories by factor analysis and were supported by both scree plot and eigen values. The variance explained by the first, second, third and fourth component was 20.89%, 19.09%, 16.33%, and 11.72% respectively. The 4 components cumulatively explained 68.03% of the total variability in the data, hence supported the extraction of 4 components. CONCLUSION: There are number of factors which enhance the stress of healthcare professionals. In Pakistan, the major stressor of medical healthcare professionals is "career & reward prospects" followed by "workplace environmental stressor". "Job demand & performance stressor" ranks third among the list of stressors and "interpersonal stressor" ranks fourth according to significance for healthcare professionals.

Improving patient care over weekends by reducing on-call work load and better time management.

The Royal College of Physicians states that "handover, particularly of temporary 'on-call' responsibility, has been identified as a point at which errors are likely to occur."[1] Working a weekend on-call covering medical wards is often busy and stressful for all junior doctors. The high volume of routine and unplanned tasks make the situation even worse. In Nevill Hall hospital Abergavenny, we measured the workload on a junior doctor for medical ward cover on weekends by counting the number of times he/she was bleeped for routine tasks. Initial study demonstrated that on average 30-40% of time on a long day shift was spent on jobs which could have been done on the preceding Friday. The "FRIDAYS" checklist was introduced for clinical staff (particularly junior doctors) to identify these jobs. According to this model, all the junior doctors were encouraged to review: F: Phlebotomy R: Rewriting drug charts I: IV fluids D: discharge summaries A: Antibiotic review Y: Yellow book/Warfarin dose S: Status of resuscitation and escalation plans before leaving the wards on Friday afternoon. This implementation successfully showed reduction in weekend workload, allowing the ward cover to be focused on care and safety of comparatively sick patients while at the same time reducing the stress for the on-call team.

Duration of lactational amenorrhoea: a hospital based survey in district Abbottabad.

BACKGROUND: The study was carried out to investigate the duration of lactational amenorrhoea in women of district Abbottabad. The objective of this survey was to determine the duration of lactational amenorrhoea in female population of district Abbottabad, NWFP, Pakistan. METHODS: A survey was conducted at Ayub Teaching Hospital from June to August 2006 by selecting admitted females and their attendants at random and subjecting them to questionnaires and interviews to collect relevant data. Majority of the sampled females belonged to different districts of Hazara division. RESULTS: Fifty nine (59) mothers of parity 1-5 were included in the study. The frequency of breast feeding ranged from 60.0% to 100% (mean 66.1%) in different pregnancies; bottle feeding frequencies ranged from 10-12.5% (mean 6.8%); frequencies of combined breast and bottle feeding ranged from 25-30% (mean 27.1%). The mean duration of lactational amenorrhoea for different pregnancies ranged from 6.0 +/- 0.0 weeks to 22.6 +/- 25.1 weeks (overall mean 15.8 +/- 15.2 weeks). Weaning times ranged from 2 to 12 months, with the mean weaning time ranging from 4.8 +/- 1.5 to 5.1 +/- 1.8 months (overall mean 4.8 +/- 1.1 months). CONCLUSION: Maternal hormonal cycles appear to be more involved in regulating the post partum amenorrhea observed in lactating mothers.

Enhanced T2 contrast for MR histology of the mouse brain.

A 3D Carr-Purcell-Meiboom-Gill (CPMG) sequence was implemented to obtain enhanced T(2) contrast in actively stained (perfusion with fixative and contrast agent) mouse brains at 9.4 T. Short interecho spacing was used to minimize diffusion and susceptibility losses. The sequence produced 16 3D volumes with an interecho spacing of 7 ms for isotropic 43-mu-resolution images of the mouse brains in a scan time of 4 hr. To enhance the signal-to-noise ratio (SNR) and contrast, the multiecho frequency domain image contrast (MEFIC) method was applied, resulting in a composite image with T(2)-weighted contrast. The high SNR and contrast thus achieved revealed aspects of mouse brain morphology, such as multiple cortical layers, groups of thalamic nuclei, layers of the inferior and superior colliculus, and molecular and granular layers of the cerebellum, with a high degree of definition and contrast that was not previously achieved in T(2)-weighted acquisitions at high fields.