Improved outcomes associated with advances in therapy for invasive fungal infections in immunocompromised hosts.

Invasive fungal infections cause substantial morbidity and mortality in immunocompromised hosts. The response rate to therapy, in particular for invasive aspergillosis and invasive mould infections, has been poor. Recently a number of techniques to facilitate early diagnosis of these infections, in parallel with the development of a number of antifungals with increased potency and lower toxicity, have raised optimism that outcomes for invasive fungal infection can be improved upon. The availability of lipid formulations of amphotericin B, azoles with extended spectrum against filamentous fungi and the development of a new class of antifungal agents, the echinocandins, presents the clinician with a range of therapeutic choices. Recent clinical trials have provided important insights into how these agents should be used. In particular, voriconazole has demonstrated superior efficacy to amphotericin B in the management of invasive aspergillosis, posaconazole has been shown to have significant efficacy in the prophylaxis of invasive fungal infection in high-risk individuals and a role in salvage therapy of invasive aspergillosis, caspofungin has demonstrated efficacy in salvage therapy of invasive aspergillosis, and each of the echinocandins show activity without significant toxicity in invasive candidiasis. Nevertheless, many therapeutic areas of uncertainty remain, including the role of combination therapy, and will provide the focus for future studies.

Invasive pneumococcal disease and the potential for prevention by vaccination in the United Kingdom.

OBJECTIVES: Invasive pneumococcal disease (IPD) is associated with a high mortality despite antimicrobial therapy, but may be preventable by pneumococcal vaccination. The extent of previous exposure to pneumococcal capsular polysaccharide vaccination prior to an episode of IPD in hospitalised adults in the United Kingdom is unclear. METHODS: We conducted a retrospective cohort study in adults with IPD admitted to either of two teaching hospitals in Sheffield, United Kingdom during 1992-2000. Receipt of pneumococcal vaccination, risk factors for IPD, death and disability were determined. RESULTS: The number of cases of IPD was 552 and 187/230 patient records from one site were reviewed. According to UK pneumococcal vaccination guidelines 59% of patients should have received the vaccine and 76% of patients if updated guidelines, which include age>65 years as an indication, are applied. In patients with known risk factors, excluding age, only 8% had been vaccinated. The mortality from IPD was 21% and an additional 6% suffered major complications. CONCLUSIONS: In patients hospitalised with IPD there is a high rate of pre-existing risk factors and a low rate of administration of pneumococcal vaccination. IPD incurs significant mortality, morbidity and economic cost and there is potential for reducing this by improved uptake of pneumococcal vaccination.

The value of book distribution in a clinic-based literacy intervention program.

The purpose of this study was to determine whether anticipatory guidance at well-child visits (WCV) that included early literacy development and the provision of books by the examining physician changed family literacy practices. It was conducted in an inner-city pediatric clinic that serves as the continuity practice site for pediatric and pediatric/internal medicine residents. There were 352 children (181 treatment: 171 control), aged 2 to 24 months, enrolled in this prospective, controlled study. The health care providers underwent training on literacy and on how to incorporate this information during WCV. Anticipatory guidance on safety, development, and early literacy was given to all parents. Additionally, the treatment group received an age-appropriate book at each WCV. There were 1,263 visits made (686 treatment, 577 control). Questionnaires were completed by parents on physician helpfulness and by physicians on parental receptiveness. Parental ratings on physician helpfulness were higher in the treatment group than in the control group (p<0.05). Physician's rating of parental receptiveness was also higher in the treatment group than in the control group (p<0.05). Two years after enrollment, mother-child pairs who received guidance and a book were two times more likely to report enjoyment in reading together than the controls who received guidance but no book. We conclude that anticipatory guidance that included early literacy development and distribution of books at WCV resulted in increased family literacy orientation, parental receptiveness, and perception of physician helpfulness.

Infant sleep position instruction and parental practice: comparison of a private pediatric office and an inner-city clinic.

OBJECTIVE: To determine infant sleep instructions that hospital personnel in our community were giving to parents and actual positions practiced after the April 15, 1992 American Academy of Pediatrics recommendation for nonprone positioning. DESIGN: Survey of mothers of infants