Changes of Dermatophytoses in Southwestern Greece: An 18-Year Survey

The isolation and distribution rate of dermatophytes as causative agents of superficial mycoses of skin, hair, and nails during an 18-year period (1991–2008) at a university hospital are presented. A comparative analysis of epidemiological differences within the first (1991–1999) and the second 9-year period (2000–2008) was performed. Skin scrapings, nail, and hair specimens were examined by a direct microscopic examination and culture. Identification of dermatophyte species was based on macroscopic and microscopic characteristics of colonies. During the complete period (18 years), 5,971 patients with suspected dermatophytosis were examined. Seven hundred and sixty-nine patients (12.8%) were found positive. Among them, 495 cases (64.3%) were of skin dermatophytoses, 91(11.8%) of hair, and 183 (23.7%) of nails. The most frequent etiological agents were Microsporum canis (54%), Trichophyton rubrum (38%), and T. mentagrophytes (6%). Epidermophyton floccosum, T. tonsurans, T. violaceum, and M. gypseum were responsible only for 16 cases (2%) of dermatophytoses. The prevalence of dermatophytoses seems to decrease significantly from 16.2% (1991–1999)–9.6% during the last 9-year period. The most frequent dermatophyte, M. canis, shows decreasing trends during the last period (from 58.5 to 45.7%), whereas T. rubrum shows an increasing isolation rate (from 35 to 43.6%), respectively. The most common form of dermatophytosis among children remains tinea capitis due to M. canis. The most frequent etiological agent of tinea unguium (81%) is T. rubrum.     

Child Mortality Estimation: Methods Used to Adjust for Bias due to AIDS in Estimating Trends in Under-Five Mortality

In most low- and middle-income countries, child mortality is estimated from data provided by mothers concerning the survival of their children using methods that assume no correlation between the mortality risks of the mothers and those of their children. This assumption is not valid for populations with generalized HIV epidemics, however, and in this review, we show how the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) uses a cohort component projection model to correct for AIDS-related biases in the data used to estimate trends in under-five mortality. In this model, births in a given year are identified as occurring to HIV-positive or HIV-negative mothers, the lives of the infants and mothers are projected forward using survivorship probabilities to estimate survivors at the time of a given survey, and the extent to which excess mortality of children goes unreported because of the deaths of HIV-infected mothers prior to the survey is calculated. Estimates from the survey for past periods can then be adjusted for the estimated bias. The extent of the AIDS-related bias depends crucially on the dynamics of the HIV epidemic, on the length of time before the survey that the estimates are made for, and on the underlying non-AIDS child mortality. This simple methodology (which does not take into account the use of effective antiretroviral interventions) gives results qualitatively similar to those of other studies.     

Septicemia due to Yersinia enterocolitica

Despite the increasing number of reports of Yersinia enterocolitica infection in humans, septicemia with this organism has remained a rare complication. A 73-year-old woman presented with fever, jaundice, hepatomegaly and cellulitis. Microorganisms isolated from both skin lesion and blood were biochemically and serologically identified as Yersinia enterocolitica, biotype 4, serotype 3 and lysotype 9b. High agglutinating titres against this organism were demonstrated in the patient''s serum. Complete recovery followed a course of gentamicin sulfate. A household pet was considered, but not proved, to be the source of this infection.     

Lemierre's Syndrome: Two Cases of Septicemia due to Fusobacterium necrophorum

Two cases of Lemierre's syndrome are reported. The first patient presented with septic shock, multiple pulmonary infiltrates and thrombophlebitis of the right internal jugular vein. The second patient had septicemia due toFusobacterium necrophorum and Peptostreptococcus micros with multiple pulmonary abscesses, cholestatic liver dysfunction and severe thrombocytopenia. Clinical course, radiological and laboratory findings and therapy are discussed.     

Mortality Trends in Women and Men Presenting with Acute Coronary Syndrome: Insights from a 20-Year Registry

Background

Coronary artery disease (CAD) is the leading cause of mortality worldwide. The present study evaluated the impact of gender in patients hospitalized with acute coronary syndromes (ACS) over a 20-year period in Qatar.

Methods

Data were collected retrospectively from the registry of the department of cardiology for all patients admitted with ACS during the study period (1991–2010) and were analyzed according to gender.

Results

Among 16,736 patients who were admitted with ACS, 14262 (85%) were men and 2474 (15%) were women. Cardiovascular risk factors were more prevalent among women in comparison to men. On admission, women presented mainly with non-ST-elevation ACS and were more likely to be undertreated with β-blockers (BB), antiplatelet agents and reperfusion therapy in comparison to men. However, from 1999 through 2010, the use of aspirin, angiotensin-converting enzyme inhibitors and BB increased from 66% to 79%, 27% to 41% and 17% to 49%, respectively in women. In the same period, relative risk reduction for mortality was 64% in women and 51% in men. Across the 20-year period, the mortality rate decreased from 27% to 7% among the Middle Eastern Arab women. Multivariate logistic regression analysis showed that female gender was independent predictor of in-hospital mortality (odd ratio 1.51, 95% CI 1.27–1.79).

Conclusions

Women presenting with ACS are high-risk population and their in-hospital mortality remains higher for all age groups in comparison to men. Although, substantial improvement in the hospital outcome has been observed, guidelines adherence and improvement in the hospital care have not yet been optimized.     

Septicemia due to coagulase-negative Staphylococcus in a community hospital.

The experience with septicemia due to coagulase-negative Staphylococcus at a 623-bed primary care hospital between 1980 and 1984 was reviewed. A total of 38 episodes in 37 patients were documented; data were available on 37 episodes in 36 patients. The organism accounted for 3.8% of all cases of septicemia and 6.7% of cases of nosocomial septicemia and was associated with 0.03% of all admissions. The incidence remained stable over the 5 years. The rate of survival 28 days after the episode was 78%. Most of the episodes (31) originated from infected vascular access sites. Of the 37 isolates 15 (41%), all S. epidermidis, were slime producing. S. epidermidis accounted for 33 of the isolates; of the 33, 5 were methicillin-resistant and slime producing. Various in-vitro susceptibility testing methods and testing for beta-lactamase production yielded conflicting results. Methicillin resistance, slime production and speciation as S. epidermidis were not confirmed as virulence markers. Five patients with methicillin-resistant organisms were treated with cephalosporins, and all recovered. These findings as well as examination of the literature do not support the recommendations that laboratories report such isolates as resistant to all beta-lactam agents and that vancomycin be given in all such infections. The different case mix in community hospitals as compared with university centres results in different patterns of nosocomial infection. Since the community hospital patient population is much larger, more information on the patterns of infections in these centres is needed.     

Septicemia due to Streptococcus mitis in neutropenic patients with acute leukemia

Eight neutropenic patients with acute lymphocytic or nonlymphocytic leukemia had septicemia due to different strains of Streptococcus mitis (St. mitis), a microorganism not commonly recognized as a special pathogen in leukemic patients. Four of the patients had been treated with high-dose cytosine arabinoside as part of the cytostatic regimen, six had a central venous line and four patients had oral lesions prior to the infection. Selective gut decontamination consisted of co-trimoxazole/colistin in five patients and quinolones in three patients. The first three patients died, either due to interstitial pneumonia with the adult respiratory distress syndrome (ARDS), or due to infection-triggered disseminated intravascular coagulation despite prompt empiric antibiotic therapy including vancomycin. The other patients improved after empiric supplementation of penicillin G (30 Mega/day) to the antibiotic regimen. Beginning ARDS in two of these patients dramatically responded to high-dose steroids. We conclude that St. mitis is a major pathogen in neutropenic leukemic patients. Infection appears to occur independently of acute leukemic cell type, regimen of selective gut decontamination, venous access, visible oral lesions or treatment with high-dose cytosine arabinoside. The clinical course of our patients raises questions about the value of commonly recommended empiric antibiotic regimens, which were clearly ineffective to control infections with St. mitis in this patient group. Our data indicate that immediate antibiotic therapy with penicillin G is indicated and may be life-saving for suspected St. mitis infections in neutropenic leukemic patients.     

Septicemia due to Solobacterium moorei in a patient with multiple myeloma

We report a case of bacteremia caused by Solobacterium moorei, an anaerobic, non-sporulated Gram-positive bacillus in a patient with a multiple myeloma. The source of infection was presumably related to multiple dento-alveolar abscesses. This is the first recovery of S. moorei from blood cultures.     

Mortality in Systemic Lupus Erythematosus: A 10-Year Review

During the years 1963-72 33 patients with systemic lupus erythematosus (S.L.E.) died. Of these 30 case records were available for analysis. For the same period 167 patients with S.L.E. were admitted. It was ascertained that of the 30 deaths 22 were directly attributable to the disease itself and 8 were related to complications of therapy. The three commonest causes of death were neurological involvement (11 patients), renal failure (9 patients), and infection (8 patients).     

Contaminant Trends in Freshwater Fish from the Laurentian Great Lakes: A 20-Year Analysis

Although dietary concerns of Laurentian Great Lakes (GL) fish focus on the risk from persistent bioaccumulative toxicant (PBT) contaminants, fish are also an important source of nutrients beneficial to human health such as polyunsaturated fatty acids (e.g., eicosapentanoic acid and docosahexanoic acid). This study presents PBT trend data from the GL tribal fisheries over the past 20 years. PBT contaminants (282 analytes) from fillet portions of lake trout and whitefish were analyzed for trending patterns from 1992 to 2011 and are reported on five of the ATSDR/USEPA Great Lakes biomonitoring legacy contaminants (Hg, ΣDDE, ΣDDT, HCB, mirex, and ΣPCBs), two of the optional biomonitoring PBTs (toxaphene and Σdioxins/furans) and PCB 153 as a specific congener marker. Similar to other recent reports our data indicate that most PBT contaminant concentrations in the GL biota have decreased, which may indicate progress in reducing environmental emissions. Our research confirms that all contaminants demonstrate significant declines except Hg and toxaphene. Both of those remained constant after correcting for known independent factors of age, lipid, and size. These results are potentially encouraging and may provide useful data for the long distance and perhaps global influences of PBTs on the safety of fish consumption.     

Age-Related Mortality Trends in Italy from 1901 to 2008

We stratified the Italian population according to age and gender in order to evaluate mortality trends over more than one century. Data covering the 1901–2008 period were used to study the yearly variations in mortality. Fluctuations in age-adjusted mortality curves were analyzed by Join Point Regression Models, identifying Join Points and Annual Percent Changes. A consistent decline in all-cause mortality occurred across the whole period, the most striking variations being observed in the 0–49 years population. In 1901, other and undefined diseases were the main causes of death, followed by infectious, digestive, and respiratory diseases in the 0–49 years population and by respiratory, cardiovascular, and cerebrovascular diseases in the ≥50 years population groups. In 2008 the main causes of death were accidents (males) and tumors (females) in the 0–49 age class, tumors in the 50–69 age class (both genders), and tumors (males) and cardiovascular diseases (females) in the elderly. The results highlight the interplay between age and gender in affecting mortality trends and reflect the dramatic progress in nutritional, lifestyle, socioeconomic, medical, and hygienic conditions.     

Olfactory Dysfunction Predicts 5-Year Mortality in Older Adults

Prediction of mortality has focused on disease and frailty, although antecedent biomarkers may herald broad physiological decline. Olfaction, an ancestral chemical system, is a strong candidate biomarker because it is linked to diverse physiological processes. We sought to determine if olfactory dysfunction is a harbinger of 5-year mortality in the National Social Life, Health and Aging Project [NSHAP], a nationally representative sample of older U.S. adults. 3,005 community-dwelling adults aged 57–85 were studied in 2005–6 (Wave 1) and their mortality determined in 2010–11 (Wave 2). Olfactory dysfunction, determined objectively at Wave 1, was used to estimate the odds of 5-year, all cause mortality via logistic regression, controlling for demographics and health factors. Mortality for anosmic older adults was four times that of normosmic individuals while hyposmic individuals had intermediate mortality (p<0.001), a “dose-dependent” effect present across the age range. In a comprehensive model that included potential confounding factors, anosmic older adults had over three times the odds of death compared to normosmic individuals (OR, 3.37 [95%CI 2.04, 5.57]), higher than and independent of known leading causes of death, and did not result from the following mechanisms: nutrition, cognitive function, mental health, smoking and alcohol abuse or frailty. Olfactory function is thus one of the strongest predictors of 5-year mortality and may serve as a bellwether for slowed cellular regeneration or as a marker of cumulative toxic environmental exposures. This finding provides clues for pinpointing an underlying mechanism related to a fundamental component of the aging process.     

HIV-Associated Histoplasmosis Early Mortality and Incidence Trends: From Neglect to Priority

Background

Histoplasmosis is an endemic fungal infection in French Guiana. It is the most common AIDS-defining illness and the leading cause of AIDS-related deaths. Diagnosis is difficult, but in the past 2 decades, it has improved in this French overseas territory which offers an interesting model of Amazonian pathogen ecology. The objectives of the present study were to describe the temporal trends of incidence and mortality indicators for HIV-associated histoplasmosis in French Guiana.

Methods

A retrospective study was conducted to describe early mortality rates observed in persons diagnosed with incident cases of HIV-associated Histoplasma capsulatum var. capsulatum histoplasmosis admitted in one of the three main hospitals in French Guiana between 1992 and 2011. Early mortality was defined by death occurring within 30 days after antifungal treatment initiation. Data were collected on standardized case report forms and analysed using standard statistical methods.

Results

There were 124 deaths (45.3%) and 46 early deaths (16.8%) among 274 patients. Three time periods of particular interest were identified: 1992–1997, 1998–2004 and 2005–2011. The two main temporal trends were: the proportion of early deaths among annual incident histoplasmosis cases significantly declined four fold (χ2, p<0.0001) and the number of annual incident histoplasmosis cases increased three fold between 1992–1997 and 1998–2004, and subsequently stabilized.

Conclusion

From an occasional exotic diagnosis, AIDS-related histoplasmosis became the top AIDS-defining event in French Guiana. This was accompanied by a spectacular decrease of early mortality related to histoplasmosis, consistent with North American reference center mortality rates. The present example testifies that rapid progress could be at reach if awareness increases and leads to clinical and laboratory capacity building in order to diagnose and treat this curable disease.     

Depression and Incident Dementia. An 8-Year Population-Based Prospective Study

Aims

The aim of the study was to investigate the impact of depression (categorical diagnosis; major depression, MD) and depressive symptoms (dimensional diagnosis and symptom patterns) on incident dementia in the German general population.

Methods

Within the Leipzig Longitudinal Study of the Aged (LEILA 75+), a representative sample of 1,265 individuals aged 75 years and older were interviewed every 1.5 years over 8 years (mean observation time 4.3 years; mean number of visits 4.2). Cox proportional hazards and binary logistic regressions were used to estimate the effect of baseline depression and depressive symptoms on incident dementia.

Results

The incidence of dementia was 48 per 1,000 person-years (95% confidence interval (CI) 45–51). Depressive symptoms (Hazard ratio HR 1.03, 95% CI 1.01–1.05), and in particular mood-related symptoms (HR 1.08, 95% CI 1.03–1.14), showed a significant impact on the incidence of dementia only in univariate analysis, but not after adjustment for cognitive and functional impairment. MD showed only a significant impact on incidence of dementia in Cox proportional hazards regression, but not in binary logistic regression models.

Discussion

The present study using different diagnostic measures of depression on future dementia found no clear significant associations of depression and incident dementia. Further in-depth investigation would help to understand the nature of depression in the context of incident dementia.     

The Synergistic Effect of Functional Status and Comorbidity Burden on Mortality: A 16-Year Survival Analysis

Objectives

The relationship between disability and comorbidity on mortality is widely perceived as additive in clinical models of frailty.

Design

National data were retrospectively extracted from medical records of community hospital.

Data Sources

There were of 12,804 acutely-disabled patients admitted for inpatient rehabilitation in Singapore rehabilitation community hospitals from 1996 through 2005 were followed up for death till 31 December 2011.

Outcome Measure

Cox proportional-hazards regression to assess the interaction of comorbidity and disability at discharge on all-cause mortality.

Results

During a median follow-up of 10.9 years, there were 8,565 deaths (66.9%). The mean age was 73.0 (standard deviation: 11.5) years. Independent risk factors of mortality were higher comorbidity (p<0.001), severity of disability at discharge (p<0.001), being widowed (adjusted hazard ratio [aHR]: 1.38, 95% confidence interval [CI]:1.25–1.53), low socioeconomic status (aHR:1.40, 95%CI:1.29–1.53), discharge to nursing home (aHR:1.14, 95%CI:1.05–1.22) and re-admission into acute care (aHR:1.54, 95%CI:1.45–1.65). In the main effects model, those with high comorbidity had an aHR = 2.41 (95%CI:2.13–2.72) whereas those with total disability had an aHR = 2.28 (95%CI:2.12–2.46). In the interaction model, synergistic interaction existed between comorbidity and disability (p<0.001) where those with high comorbidity and total disability had much higher aHR = 6.57 (95%CI:5.15–8.37).

Conclusions

Patients with greater comorbidity and disability at discharge, discharge to nursing home or re-admission into acute care, lower socioeconomic status and being widowed had higher mortality risk. Our results identified predictive variables of mortality that map well onto the frailty cascade model. Increasing comorbidity and disability interacted synergistically to increase mortality risk.     

An Analysis of Factors Linked to the Decline in Maternal Mortality in Nepal

Nepal experienced a steep decline in maternal mortality between 1996 and 2006, which had again dropped by 2010. The aim of this study was to investigate any trends in factors that may be responsible for this decline. The study was based on a secondary data analysis of maternity care services and socio-demographic variables extracted from the Nepal Demographic Health Surveys (1996, 2001, 2006 and 2011). Complex sample analysis was performed to determine the trends in these variables across the four surveys. Univariate logistic regression was performed for selected maternity care service variables to calculate the average change in odds ratio for each survey. Multivariate logistic regression was performed to determine the trends in the health service uptake adjusting for socio-demographic variables. There were major demographic and socio-economic changes observed between 1996 and 2011: notably fewer women delivering at ‘high risk’ ages, decreased fertility, higher education levels and migration to urban areas. Significant trends were observed for improved uptake of all maternity care services. The largest increase was observed in health facility delivery (odds ratio = 2.21; 95% confidence interval = 1.92, 2.34) and women making four or more antenatal visits (odds ratio = 2.24; 95% confidence interval = 2.03, 2.47). After adjusting for all socio-demographic factors, the trends were still significant but disparities become more pronounced at the extremes of the socio-economic spectrum. The odds ratios for each maternity care service examined decreased slightly after adjusting for education, indicating that improved levels of education could partly explain these trends. The improved utilisation of maternity care services seems essential to the decline in maternal mortality in Nepal. These findings have implications for policy planning in terms of government resources for maternity care services and the education sector.     

Glaucoma,Alzheimer's Disease,and Parkinson's Disease: An 8-Year Population-Based Follow-Up Study

BackgroundGlaucoma is the leading cause of irreversible blindness worldwide and primary open-angle glaucoma (POAG) is the most common type of glaucoma. An association between POAG and the subsequent risk of Alzheimer''s disease (AD) and Parkinson''s disease (PD) was unclear.ObjectiveTo investigate the association between POAG (including normal-tension glaucoma) and the subsequent risk of AD or PD 8 years following a diagnosis of POAG.MethodsWe performed a retrospective, propensity-score-matched analysis of a population-based cohort consisting of patients with and without POAG aged 60 years and older. Control patients without POAG were propensity-score matched to POAG patients based on their baseline characteristics.ResultsThe incidence rates and confidence intervals (CIs) of AD among the patients with and without POAG were 2.85 (95% CI: 2.19–3.70) and 1.98 (95% CI: 1.68–2.31) per 1000 person-years, respectively. The incidence rates of PD among the POAG and non-POAG cohorts were 4.36 (95% CI: 3.52–5.39) and 4.37 (95% CI: 3.92–4.86) per 1000 person-years, respectively. Kaplan-Meier failure curves showed that the POAG patients had a higher risk of AD than the control patients did (log-rank test, P = .0189). However, the cumulative PD hazard ratios for the POAG and non-POAG patients did not differ significantly (log-rank test, P = .9953).ConclusionIn elderly patients, POAG is a significant predictor of AD, but POAG is not a predictor of PD.