Significant Psychosocial Influence in Frail People Living with HIV Independent of Frailty Instrument Used.

BACKGROUND: Antiretroviral therapy (ART) usage among people living with HIV (PLWH) has led to significant mortality declines and increasing lifespan. However, high incidence and early onset of aging-related conditions such as frailty, pose as a new threat to this population. OBJECTIVES: We aimed to characterize frailty by comparing health domains consisting of psychosocial, functional and physical deficits between frail PLWH and matched uninfected controls; identify associated risk factors and the impact on negative health outcomes including mortality risk score, quality of life, healthcare utilization, functional disability and history of falls among virally suppressed PLWH. DESIGN: Cross-sectional study. SETTING: Infectious disease clinic in a tertiary institution. PARTICIPANTS: Individuals aged >25 years, on ART >12 months, not pregnant and without acute illness; multi-ethnic, Asian. MEASUREMENTS: Frailty instruments included Frailty phenotype (FP), FRAIL scale (FS) and Frailty index (FI). FI health deficits were categorized into health domains (psychosocial, functional and physical) and used as standard comparator to characterize frailty. Health domains of frail PLWH were compared with frail matched, uninfected controls. Regression analyses were applied to explore associated risk factors and health-related frailty outcomes. RESULTS: We recruited 336 PLWH. Majority were male (83%), Chinese (71%) with CD4+ count 561 (397-738) cells/µl. Frailty prevalence among PLWH were 7% (FP); 16% (FS) and 22% (FI). Proportions of psychosocial, functional, and physical domains were similarly distributed among frail PLWH measured by different frailty instruments. When compared with matched controls, psychosocial dominance was significant among the PLWH, but not in functional and physical domains. Identified frailty risk factors included poor nutritional status, higher CD4+ count nadir, depression, metabolic syndrome, higher highly sensitive C-reactive protein (hsCRP) and history of AIDS-defining illness (ADI). Frailty influenced the risk for negative health outcomes including increased mortality risk scores, poor quality of life (QOL), frequent healthcare utilization and increased functional disability (p<0.05). CONCLUSIONS: This study highlighted the importance of psychosocial influence in the development of frailty among treated PLWH in a multi-ethnic, Asian setting.

Nocardia kroppenstedtii: a rare pathogen isolated from the spinal vertebral abscess of a patient on long-term immunosuppressive therapy.

OBJECTIVE: Nocardia kroppenstedtii was isolated from the spinal vertebral abscess of a 78-year-old patient presenting with mid-thoracic pain and bilateral lower limb weakness and numbness. The patient was on long-term immunosuppressive therapy with steroids for underlying autoimmune hemolytic anemia. Investigations showed a T5 pathological fracture and vertebra plana with the erosion of the superior and inferior endplates. There was evidence of paraspinal collection from the T4-T6 vertebrae with an extension into the spinal canal. Analysis of Nocardia 16S rRNA (99.9%, 1395/1396 nt) and secA1 gene (99.5%, 429/431 nt) fragments showed the highest sequence similarity with Nocardia kroppenstedtii type strain (DQ157924), and next with Nocardia farcinica (Z36936). The patient was treated with intravenous carbapenem and oral trimethoprim-sulfamethoxazole for four weeks, followed by another six months of oral trimethoprim-sulfamethoxazole. Despite the improvement of neurological deficits, the patient required assistive devices to ambulate at discharge. This study reports the first isolation of N. kroppenstedtii from the spinal vertebral abscess of a patient from Asia. Infections caused by N. kroppenstedtii may be underdiagnosed as the bacterium can be misidentified as N. farcinica in the absence of molecular tests in the clinical laboratory.

Human Immunodeficiency Virus-infected men who have sex with men with syphilis: A 5-year multicentre study in Malaysia.

OBJECTIVES: High rates of syphilis have been reported worldwide among men who have sex with men (MSM). This study aims to describe the clinical pattern and treatment response of syphilis among human immunodeficiency virus (HIV)-infected MSM in Malaysia. METHODS: This is a retrospective study on all HIV-infected MSM with syphilis between 2011 and 2015. Data was collected from case notes in five centres namely Hospital Kuala Lumpur, Hospital Sultanah Bahiyah, Hospital Umum Sarawak, University of Malaya Medical Centre and Hospital Sungai Buloh. RESULTS: A total of 294 HIV seropositive MSM with the median age of 29 years (range 16-66) were confirmed to have syphilis. Nearly half (47.6%) were in the age group of 20-29 years. About a quarter (24.1%) was previously infected with syphilis. Eighty-three patients (28.2%) had other concomitant sexually transmitted infection with genital warts being the most frequently reported (17%). The number of patients with early and late syphilis in our cohort were almost equal. The median pre-treatment non-treponemal antibody titre (VDRL or RPR) for early syphilis (1:64) was significantly higher than for late syphilis (1:8) (p<0.0001). The median CD4 count and the number of patients with CD4 <200/µl in early syphilis were comparable to late syphilis. Nearly four-fifth (78.9%) received benzathine-penicillin only, 5.8% doxycycline, 1.4% Cpenicillin, 1% procaine penicillin, and 12.4% a combination of the above medications. About 44% received treatment and were lost to follow-up. Among those who completed 1 -year follow-up after treatment, 72.3% responded to treatment (serological non-reactive - 18.2%, four-fold drop in titre - 10.9%; serofast - 43.6%), 8.5% failed treatment and 17% had re-infection. Excluding those who were re-infected, lost to follow-up and died, the rates of treatment failure were 12.1% and 8.8% for early and late syphilis respectively (p=0.582). CONCLUSION: The most common stage of syphilis among MSM with HIV was latent syphilis. Overall, about 8.5% failed treatment at 1-year follow-up.

Clinical prediction models for ESBL-Enterobacteriaceae colonization or infection: a systematic review.

BACKGROUND: ß-Lactamase resistance among certain Gram-negative bacteria has been associated with increased mortality, length of hospitalization, and hospital costs. AIM: To identify and critically appraise existing clinical prediction models of extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-EKP) infection or colonization. METHODS: Electronic databases, reference lists, and citations were searched from inception to April 2018. Papers were included in any language describing the development or validation, or both, of models and scores to predict the risk of ESBL-EKP infection or colonization. FINDINGS: In all, 1795 references were screened, of which four articles were included in the review. The included studies were carried out in different geographical locations with differing study designs, and inclusion and exclusion criteria. Most if not all studies lacked external validation and blinding of reviewers during the evaluation of the predictor variables and outcome. All studies excluded missing data and most studies did not report the number of patients excluded due to missing data. Fifteen predictors of infection or colonization with ESBL-EKP were identified. Commonly included predictors were previous antibiotic use, previous hospitalization, transfer from another healthcare facility, and previous procedures (urinary catheterization and invasive procedures). CONCLUSION: Due to limitations and variations in the study design, clinicians would have to take these differences into consideration when deciding on how to use these models in clinical practice. Due to lack of external validation, the generalizability of these models remains a question. Therefore, further external validation in local settings is needed to confirm the usefulness of these models in supporting decision-making.

Determination of thin hydrodynamic lubricating film thickness using dichromatic interferometry.

This paper introduces the application of dichromatic interferometry for the study of hydrodynamic lubrication. In conventional methods, two beams with different colors are projected consecutively on a static object. By contrast, the current method deals with hydrodynamic lubricated contacts under running conditions and two lasers with different colors are projected simultaneously to form interference images. Dichromatic interferometry incorporates the advantages of monochromatic and chromatic interferometry, which are widely used in lubrication research. This new approach was evaluated statically and dynamically by measuring the inclination of static wedge films and the thickness of the hydrodynamic lubricating film under running conditions, respectively. Results show that dichromatic interferometry can facilitate real-time determination of lubricating film thickness and is well suited for the study of transient or dynamic lubricating problems.

A review on frozen shoulder.

Of all the joints in the human body, the shoulder has the greatest range of motion. This allows complex movements and functions to be carried out, and is of vital importance to the activities of daily living and work. Any restriction or pain that involves the joint puts a huge amount of strain on patients, especially those who are in their most productive years of life. Frozen shoulder, a frequently encountered disorder of the shoulder, has been well recognised since the early 1900s. Although benign, it has great impact on the quality of life of patients. This article aims to provide an overview of the nature and the widely accepted management of this condition based on other studies.

[A man with Campylobacter endocarditis, treatable as Campylobacter fetus following identification]. / Een man met een Campylobacter-endocarditis, na determinatie behandelbaar als Campylobacter fetus.

A 48-year-old Dutch patient presented with general malaise, recurrent fever and weight loss. Routine cultures identified a Campylobacter in two blood cultures. When initial treatment with clarithromycin failed, the patient developed endocarditis. DNA sequencing identified Campylobacter fetus subspecies fetus (C. fetus). The patient recovered after treatment of the infection with imipenem and gentamycin, based on the minimal inhibiting concentration. C. fetus is a rare cause of infection in humans and is mostly transmitted by handling infected animal material. The patient contracted the infection as a result of a puncture accident with a butcher's knife about a year previously whilst working in a slaughterhouse.

Medicaid managed care in Texas. What have we learned from the pilots?

Texas has a plan for statewide implmentation of Medicaid managed care by 2001. This article presents evidence from initial demonstration projects, which were implemented in 1993. The 1st-year experience is described and preliminary effects are examined in terms of reactions of clients and providers and changes in utilization patterns and costs of care. Results of the evaluation indicate implementation difficulties with several operational aspects of managed care, variable effects in terms of client and provider reaction to the reform, and little or no change in utilization patterns, but significant cost-savings to the state. Because of the implementation difficulties identified by the evaluation and the mixed results regarding effects, further research is recommended to determine the potential benefit of this reform.

Submaximal oxygen pulse divided by body weight during incremental exercise test.

The purpose of this study was to examine whether submaximal oxygen pulse divided by body weight (O2 pulse/BW) during an incremental exercise test discriminated between trained and untrained men, correlated to left ventricular ejection fraction (LVEF) at rest in post-myocardial infarction patients, and was sensitive and specific in detecting ventricular dysfunction and mild ventricular dysfunction with myocardial ischemia during exercise. Forty-three trained men, 44 untrained men, and 21 post-myocardial infarction patients pedaled a cycle ergometer, with O2 consumption, heart rate, and myocardial ischemia monitored during the exercise test. Work rate started at 10 W and increased 10 W/min stepwise; the O2 pulse and O2 pulse/BW at 10 through 120 W were calculated. The LVEF of the patients was measured at rest using radionuclide ventriculography three weeks after myocardial infarction. The results revealed that O2 pulse/BW was significantly different between trained and untrained men at 80, 90, 100, 110, and 120 W, whereas O2 pulse was significantly different only at 110 and 120 W. Oxygen pulse/BW at 10 W, as well as 30 through 120 W, significantly correlated to LVEF in the patients. The three patients with ventricular dysfunction (LVEF, < 40%) plus the two patients with mild ventricular dysfunction (LVEF between 40 and 50%) and ST segment depression during exercise all had submaximal O2 pulse/BW significantly lower than untrained men (sensitivity, 100%). Among the 11 patients with normal ventricular function (LVEF, > 50%) plus the 5 patients with mild ventricular dysfunction but no ST segment depression, 13 patients did not have submaximal O2 pulse/BW significantly lower than untrained men (specificity, 81%).

A prospective randomized comparison of single versus multidose gentamicin in the treatment of CAPD peritonitis.

There is an increasing trend towards the use of aminoglycosides in a once-daily dose administration for the treatment of severe infections in nonrenal failure patients. The use of once-daily dose aminoglycoside therapy may be associated with a reduction in toxicity. We performed a prospective randomized study comparing once-daily versus multiple-dose gentamicin in the treatment of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. Seventy-three patients with 100 new episodes of peritonitis were enrolled in the study. At presentation of peritonitis, the patients were alternately assigned to receive either intraperitoneal gentamicin at a dose of 40 mg/2 L dialysate administered as a once-daily dose or gentamicin at a dose of 10mg/2 L dialysate administered 4 times per day. All patients also received intraperitoneal vancomycin at a dose of 1 g per week. There were no significant differences in the treatment success (88% vs 82%, p = NS) and relapse (18% vs 20%, p = NS) rates between the once-daily dose and multiple-dose groups. The mean trough serum gentamicin level was higher in the once-daily dose group compared to the multiple-dose group (0.75 +/- 0.72 vs 1.50 +/- 1.40 mg/L). In conclusion, gentamicin administered in a once-daily dose is as effective as multiple-dose administration in the treatment of CAPD peritonitis. The lower gentamicin level with once-daily dose administration may be associated with a reduction in aminoglycoside toxicity.

Effects of beta 2-adrenergic agonists on isolated guinea pig lung mast cells.

The mast cell protective effects of the newly developed long-acting beta 2-agonists salmeterol and formoterol were compared with those of conventionally used beta 2-agonists, non-specific beta-agonists, disodium cromoglycate (DSCG) and theophylline. With the exception of DSCG, all the test agents inhibited ovalbumin-induced histamine release from enzymically dispersed guinea pig lung mast cells in a dose-dependent fashion. At the maximum concentration tested, theophylline produced the highest level of protection, inhibiting up to 90% of ovalbumin-induced histamine release whereas DSCG produced only 10% inhibition. The maximum inhibition produced by all the beta 2-agonists tested was around 45%. While salmeterol was equipotent with salbutamol, formoterol was at least a 100-fold more potent. Hence the present study confirmed the previously reported mast cell stabilizing actions of conventional beta 2-agonists and extended the observation to the newly developed long-acting analogues.

Effects of long-acting beta 2-adrenoceptor agonists on mast cells of rat, guinea pig, and human.

The effects of two recently developed long-acting beta 2-adrenoceptor agonists, formoterol and salmeterol, on mast cells from different sources were compared with those of the prototype short-acting analogue, salbutamol. With the exception of high concentrations of salmeterol (> 10(-5) M), none of the tested beta 2-adrenoceptor agonists inhibited the anti-IgE-induced histamine release from rat peritoneal mast cells. In contrast, all three compounds dose dependently inhibited the immunologically induced histamine release from isolated lung mast cells of guinea pig and human at concentrations < or = 10(-5) M.

Isolation of organisms in CAPD peritonitis: a comparison of two techniques.

The identification of organisms is important in the treatment of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. We compared two techniques for isolating organisms in CAPD peritonitis. Clinical and microbiologic data on all episodes of peritonitis from 1991-1993 were prospectively recorded. The isolation of organisms from 77 episodes of peritonitis was done using the conventional centrifugation culture method from 1991-1992; the isolation of organisms from 121 episodes of peritonitis was done using the BACTEC method from 1992-1993. The total culture-positive rates were 75% for the BACTEC technique and 58% for the conventional technique (p = 0.05), with a higher isolation rate for gram-negative organisms (36% vs 18%, p < 0.05). In the isolation of organisms from new episodes of peritonitis, the culture-positive rates were significantly higher for the BACTEC than for the conventional technique (82% vs 55%, p < 0.01). The recovery rates of organisms for both techniques were similar for relapse peritonitis. The treatment outcomes of CAPD peritonitis for the two technique groups, and for the culture-positive and culture-negative groups were not significantly different. In conclusion, the BACTEC method yielded a higher rate of positive cultures for CAPD peritonitis, but did not affect treatment outcome of the infections.

Clinical survey of antibodies against red blood cells in horses after homologous blood transfusion.

Serum samples of 20 horses were evaluated for antibodies against RBC after homologous blood transfusion. Transfusion-associated antibodies against RBC were detected in 10 horses. Antibodies recognizing horse blood group antigens Aa, Ae, Db, and Dc were identified. Antibodies against Aa were found in all samples from Aa-negative horses that were transfused with Aa-positive RBC. Antibodies against Aa persisted for at least 1 year after transfusion. Antibodies against Ae were detected in 7 of 8 horses transfused with Ae-positive RBC. Initial appearance and persistence of antibodies against Ae differed among the horses; antibodies were initially detected 1 week to 154 weeks after transfusion and disappeared as early as 4 weeks after transfusion. Antibodies against Db or Dc were detected in less than or equal to 33% of the horses that lacked Db or Dc antigens and were transfused with Db- or Dc-positive RBC. Antibodies against Db and Dc were initially detected in sera later than were the A-system antibodies. Three mares with transfusion-associated antibodies subsequently produced healthy offspring. Two foals had RBC antigens corresponding to their dam's alloantibodies; maternal colostrum with antibodies against Aa was withheld from the Aa-positive foal. The Db-positive foal remained healthy after nursing the mare with serum antibodies against Db.

Synovial membrane changes after experimental transection of the cranial cruciate ligament in dogs.

Degenerative joint disease and inflammation of the synovial membrane were produced in the left stifle of 16 dogs by severing the cranial cruciate ligament. Arthrotomy only was performed on the right stifle. Synovial membrane from these joints was histologically examined at 1, 2, 8, and 13 weeks after surgical operation. Similar tissue was obtained from 4 healthy dogs for comparison. Inflammatory changes in the synovium of the left stifle progressed with time and were prominent at 8 weeks postoperatively; subsynovial fibrosis was greatest at 13 weeks. Inflammation of the synovial membrane and subsynovial tissue was characterized by synovial cell hypertrophy and hyperplasia, plasma cell and lymphocyte infiltration, and increased vascularization of the subsynovial region.