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Download Download this free, 150-page Pharmaceutical Serialization Playbook jam-packed with strategies for success and pitfalls to avoid. Learn more >>
Article | November 30, 2002
Aline Heat Seal Corporation: Tabletop sealer
The Aline (Cerritos, CA) MPD-SS stainless-steel medical tabletop sealer is ideal for all medical applications where budget or space concerns are paramount.
Pneumatically operated unit is available in a 15" 20" and 25" seal length. Digital temperature controller allows users to program the temperature settings required to give the product an airtight/watertight seal. Sealer is validatable and FDA/NIST traceable. Features include calibration ports digital heat timer pressure gauge and regulator and a tap-to-start foot pedal.
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text:
Message loops
Expand Messages
- Hi Group,
The issue is: When I leave this Message service loop running and my
computer Fedora 11 go into a screen saver and lock the screen logging
back into my computer takes an inordinate amount of time. It should be
noted: I launch this function with a button on my main GUI
(RadioControl) and I don't get the delay if my program is waiting in its
main message loop. I am confused?
Kerry N0WIQ
My web site URL is:
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subset: commoncrawl


text:
The Power of Independent Thinking
Ivan Eland on Henry Paulsons Accusation
Recorded: Monday, February 1, 2010
Originally aired on 2/1/10 on Russia Today. Senior Fellow Ivan Eland comments on former U.S. Treasury Secretary Henry Paulson's allegation that Russia attempted to undermine the American economy shortly before the global recession.
Experts: Ivan ElandType: TelevisionIssues: Banking and Finance, Diplomacy and Foreign Aid, Politics
Against Leviathan: Government Power and a Free Society
Recorded: Wednesday, September 29, 2004
September 29, 2004
Oakland, CA
What is fundamentally wrong with government today? Since 2001, despite low inflation, federal spending has increased by a massive 28.8%, creating the largest deficits in U.S. history and the highest rate of government growth since the "guns-and-butter" presidencies of Richard Nixon and Lyndon Johnson. At the same time, federal agencies have been given new powers to secretly search anyone's property and intercept phone, Internet, and other communications, as well as inspect health and financial records. In the immediate aftermath of 9/11, economist and historian Robert Higgs alone predicted this explosion of government power, as politicians have again taken full advantage of a frightened American public.
At this special Independent Policy Forum based on his new book, Against Leviathan, Dr. Higgs will present an unflinchingly critical analysis of the abuse of government power, including pork, the welfare state, protectionism, trampling on the Bill of Rights, and governmental responses to a continuing stream of "crises," including foreign wars, both hot and cold. Dr. Higgs combines an economist's analytical scrutiny, an historian's respect for the facts, and a refusal to accept the standard excuses and cruelties of government officialdom.
Robert Higgs
Senior Fellow in Political Economy for The Independent Institute and Editor of the Institute's quarterly journal, The Independent Review: A Journal of Political Economy
Author, Against Leviathan: Government Power and a Free Society
David J. Theroux
Founder and President, The Independent Institute
Experts: Robert HiggsType: Independent Institute EventIssues: Bureaucracy and Government, Civil Liberties/ Human Rights, Democracy, History (U.S), Political Ideology and Philosophy, Politics


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Radisson Hotel Cross Keys Baltimore
Radisson Hotel Cross Keys Baltimore
Hotel Guest Rating: 8.1/10
5100 Falls Road
Baltimore, MD 21210
Hotel Freebies Available*
• Free Internet in Room show dates
• Free Parking show dates
Welcome to the Radisson Hotel Cross Keys Baltimore
On 72 wooded acres, the Radisson Hotel Cross Keys Baltimore gets points for its peaceful location about five miles from downtown, convenient to the sights but away from the hustle and bustle.
Hotel Features
In the historic neighborhood of Roland Park, the Radisson Hotel has the feel of a resort. Tennis courts and a sparkling swimming pool are open during the summer months, so the place is a favorite with families. The four-story hotel, with 147 non-smoking rooms, has screened windows you can throw open to catch the breeze. Dials let you decide how firm you want the bed to be, so you're sure to sleep like a baby. Wi-Fi is on the house, so you can always be in touch with home or the office. A bar and restaurant are on the premises, so you never have to leave the hotel unless you want to check out the other options in the neighborhood. There's also room service if you don't even want to leave the privacy of your room.
Hotel Location
About five miles north of downtown, the hotel sits in a secure gated community. The city's sights are easily accessibly by car, and there's a courtesy van that shuttles guests to the Baltimore Aquarium and the other attractions on the Inner Harbor. Johns Hopkins University is a quick three-mile drive south, as is the Baltimore Museum of Art. Baltimore-Washington Thurgood Marshall International Airport, the region's main gateway, is 17 miles south.
Guest Favorites
With a get-away-from-it-all feel, the Radisson Hotel Cross Keys Baltimore has amenities that you won't often find in a downtown hotel, including tennis courts. The courtesy shuttle downtown is a great perk.
Radisson Hotel Cross Keys Baltimore Amenities
- 24-hour front desk
- Accessible facilities
- Accessible room
- Air conditioning
- Baggage hold
- Banquet facilities
- Brailed elevators
- Bus parking
- Business center
- Cable television
- CNN available
- Complimentary in-room coffee or tea
- Complimentary newspaper delivered to room
- Connecting rooms
- Elevators
- ESPN available
- Exercise gym
- Express check-out
- Fax service
- Fitness center on-site
- Free high speed internet connection
- Free parking
- Front desk
- Hairdryer
- HBO available
- Health club
- High speed internet access for laptop in public areas
- Hot breakfast
- Housekeeping - daily
- Indoor parking
- Iron
- Ironing board
- Laundry/Valet service
- Lounges/bars
- Meeting rooms
- Non-refundable charge for pets
- Non-smoking rooms (generic)
- Outdoor parking
- Outdoor pool
- Pay per view movies on TV
- Pets allowed
- Photocopy center
- Recreational vehicle parking
- Restaurant
- Room service
- Security
- Spa
- Wheel chair access
- Wireless internet connection in public areas
Hotel Information
You must show a valid photo ID and credit card upon check-in. Please note that all special requests cannot be guaranteed and are subject to availability upon check-in. Additional charges may apply. Guests are required to show a photo identification and credit card upon check-in. Please note that all Special Requests are subject to availability and additional charges may apply.
Hotel Guest Reviews of the Radisson Hotel Cross Keys BaltimoreOur hotel ratings and reviews are from real hotel guests. Priceline.com ensures that its reviews are guests-only by proactively sending hotel surveys to customers after they've completed their hotel stays. In the post-stay surveys, priceline.com hotel customers are asked a number of questions about their stay and the hotel. On a scale of 1-10 with 10 being the best, the survey asks guests to rate their overall experience and specifically rate the hotel's cleanliness, staff and location. Priceline.com does not allow site visitors to post unsolicited hotel reviews.
Sort by: All Travelers | Business Traveler(25) | Solo Traveler(17) | Traveling as Couple(45) | Family with Young Children(16) | Family with Teens(9) | Senior Traveler(2) | Group Traveler(5)
Verified Hotel Guest from Rochester, NY
January 5, 2016
Solo Traveler
January 5, 2016
Solo Traveler
Great hotel experience. Friendly staff.
Slightly hard to find. GPS doesn't send directly there
Verified Hotel Guest from Owings Mills, MD
January 5, 2016
January 5, 2016
Friendly front desk, and breakfast sent to room. I LOVE the magnifying mini mirror in the bathroom!
My room did not have a mini fridge, and the windows didn't even crack. It was stuffy.
Ugur from Brooklyn, NY
December 8, 2015
December 8, 2015
i was checking my old bills after a month and i saw a charge from them about $89 for nothing!!! i called them and they've told me that they were really sorry and they were reimbursed the money. it's been a month and nothing happened. DO NOT STAY!!!!
Verified Hotel Guest from St Augustine, FL
November 18, 2015
November 18, 2015
Location. Great breakfast place next door. Parking
Very Large room with plenty of spaced and King headboard, but only Queen Bed instead of reserved King
Verified Hotel Guest from Baltimore, MD
November 3, 2015
November 3, 2015
The hotel staff was friendly and very helpful during my stay. The room was very clean and the beds were comfy. The hotel was also convenient to the restaurants and the beltway
Verified Hotel Guest from Pittsburgh, PA
October 7, 2015
Business Traveler
October 7, 2015
Business Traveler
It is a dump
Verified Hotel Guest from Ranson, WV
September 26, 2015
September 26, 2015
Over all a good place to stay
Location in a gated mall
Verified Hotel Guest from Clifton, NJ
August 16, 2015
August 16, 2015
quiet. clean. a/c was great. beds very comfortable.
we had a nice room and the view was very pleasant until you looked down and you find yourself looking at equipment on top of the roof of the lower floors that was quite unsightly.
Thomas from Clarksburg, NJ
August 12, 2015
Family Traveling with Teens
August 12, 2015
Family Traveling with Teens
The staff was friendly and there was decent complimentary coffee and water in the room.
I'd rate this hotel three stars at most. Everything about the hotel screams "age" - from the dingy parking garage to rickety elevators. There was an unpleasant smell that wasn't quite that of cigarette smoke (it's a non-smoking hotel) or musty.
James from Lenox, MA
July 18, 2015
Business Traveler
July 18, 2015
Business Traveler
Very short stay - overall experience somewhat limited!
No - just a little difficult to find late at night - very little hotel markings to denote their exact location
Reviews of Radisson Hotel Cross Keys Baltimore
(1 - 10 of 130 reviews)
(1 - 10 of 130 reviews)
from $108
- Mt. Washington Conference Center (1.0mi)
- Charming 1920's Stucco Home (1.1mi)
- Inn At The Colonnade Baltimore, A Doubletree By Hilton Hotel from $109 (2.1mi)
- Red Roof Inn Baltimore from $69 (2.7mi)
- Econo Lodge Baltimore from $64 (2.8mi)
- Petit Louis Bistro (0.6mi)
- Chiyo Sushi (0.9mi)
- Crêpe du Jour (0.9mi)
- Crepe Du Jour (0.9mi)
- Desert Cafe (0.9mi)
- Baltimore Museum of Art (2.5mi)
- Maryland Zoo in Baltimore (2.8mi)
- Walters Art Museum (4.4mi)
- USS Constellation (4.5mi)
- Camden Yards (5.0mi)
- Brooklyn, MD (5.1 mi)
- Halethorpe, MD (6.3 mi)
- Gwynn Oak, MD (6.7 mi)
- Rosedale, MD (7.1 mi)
- Towson, MD (8.1 mi)
- Parkville, MD (8.1 mi)
- Linthicum Heights, MD (8.2 mi)
- Catonsville, MD (8.6 mi)
- Elkridge, MD (9.3 mi)
- Glen Burnie, MD (9.7 mi)
- Essex, MD (9.9 mi)
- Pikesville, MD (10.0 mi)
- Nottingham, MD (11.2 mi)
- Hanover, MD (11.2 mi)
- Lutherville Timonium, MD (12.0 mi)
- Ellicott City, MD (13.4 mi)
- Cockeysville, MD (14.3 mi)
- Owings Mills, MD (15.1 mi)
- Hunt Valley, MD (15.5 mi)
- Lutherville Timonium, MD (16.0 mi)
- Ellicott City, MD (16.0 mi)
- Jessup, MD (16.8 mi)
- Columbia, MD (16.9 mi)
- White Marsh, MD (17.3 mi)
- Millersville, MD (17.9 mi)
- Odenton, MD (17.9 mi)
- Columbia, MD (20.0 mi)
- Jessup, MD (21.0 mi)
- Laurel, MD (29.0 mi)
- Aberdeen, MD (45.0 mi)
Most Popular Guest-Rated Hotels in Baltimore
- Residence Inn Baltimore Inner Harbor
- Baltimore Marriott Waterfront
- The Inn At Henderson's Wharf, An Ascend Hotel Collection Member
Most Popular Business-Friendly Hotels in Baltimore
- Mt. Washington Conference Center
- Sleep Inn & Suites Downtown Inner Harbor
- Homewood Suites By Hilton Baltimore
Most Popular Romantic Hotels in Baltimore
- Pier 5, An Ascend Hotel Collection Member
- Baltimore Marriott Waterfront
- Monaco Baltimore, A Kimpton Hotel
Most Popular Family-Friendly Hotels in Baltimore
- Hampton Inn Baltimore-Downtown-Convention Center
- Residence Inn Baltimore Inner Harbor
- Home2 Suites Baltimore Downtown


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Loved it! I said it all above. Sorry. Great food. Grey service! This is a popular local restaurant. That is a good thing. The atmosphere does not embrace e romance bit the food and service quality does.
What is Certificate of Excellence?
TripAdvisor awards a Certificate of Excellence to accommodations, attractions and restaurants that consistently earn great reviews from travelers.


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< Back to front page Text size – +
Patriots re-sign Forston, Green to practice squad
Posted by Mike Whitmer, Globe Staff November 28, 2013 10:49 AM
The Patriots are conducting a short practice Thursday before breaking for Thanksgiving, but there is no media access to the players. The team has announced, though, that it has re-signed defensive lineman Marcus Forston and defensive back Justin Green to the practice squad.
Forston has flip-flopped between the active roster and practice squad this season, appearing in three games and being credited with three tackles. Green was promoted from the practice squad to the active roster and played in last Sunday night's game against the Broncos.
News, analysis and commentary from Boston.com's staff writers and contributors, including Zuri Berry and Erik Frenz.
Tweets from @GlobePatriots/boston-com-patriots
get updates
browse this blogby category


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Mumsnet has not checked the qualifications of anyone posting here. If you have any medical concerns we suggest you consult your GP.
Advice on real life views on getting sterilised or mirena coil?(2 Posts)
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text:
iHerb Customer Reviews
nutribiotic GSE
1 person found the following review helpful
Posted by Reviewer1572338 on Jun 30, 2009
great for boosting your immune system
Added benefit from this product is improved urinary flow.
1 person found the following review helpful
Posted by Reviewer1598869 on Feb 09, 2012
This product arrived when I had a bad bronchial cough. It seemed to accelerate my recovery time.
Not the same product that I bought previously
1 person found the following review helpful
Posted by Zambini on Apr 22, 2012
BUYER BEWARE> They have changed the product. The packaging isn't the same. Read the ingredients. It is no longer just GSE, they have added 400 mg of other ingredients. We bought two bottles to replenish our supply. They don't work as well or quickly for our purposes with the added ingredients. We are not just looking for another cold relief, we are looking for PURE GSE to tame yeast. The capsules used to be a nice option to avoid the nasty taste of the liquid. Unless I can buy them in pure form again, it is back to the liquid GSE
great stuff
Posted by Reviewer2116616 on Jun 17, 2011
I love this stuff, always used the drops, this seems to work as well when run down.
great for spots
Posted by Reviewer1141242 on Jun 30, 2011
This stuff here is great for any kind of spots it makes them vanish in no time better than antibiotics


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A plane crash at the Georgetown Airport on Jan. 8 flipped a plane but left the pilot, the sole occupant, relatively uninjured.
Mark Hornsby, 53, of Jackson, La., was flying out to visit a friend, Lt. Tim Becker of the El Dorado County Sheriff's Office said, when he discovered as he was landing that the runway was shorter than he thought.
"One wheel went off the runway," Becker said, and the plane, a fixed-wing single-engine Van's Aircraft RV-4, flipped over into the mud beside the runway. He sustained "minor injuries, some cuts to his face," Becker said.
Hornsby was able to get out of the aircraft by himself and declined any medical attention.


text:
Anna Slater, Chief Reporter - North London and East London / / News
Barnet FC's chairman has announced plans to sell off its former stadium in Underhill, which he says is "deteriorating fast".
The Bees spent 106 years at the site but the club claims it was "ushered out" by Barnet Borough Council, which increased the cost of the lease.
Before the club moved full-time to its training complex at The Hive, in Camrose Avenue, Edgware, unimpressed supporters launched a Back 2 Barnet campaign in the hope of raising £75,000 to submit their own planning application for a new stadium in Barnet.
When asked about plans for the future of Underhill, Mr Kleanthous said in an interview on the club website: "We are now looking to sell the site.
"We have had (Rugby League team) London Broncos using the facilities keeping it ticking over but it is clearly deteriorating fast.
"The cost of maintaining the old stadium seems disproportionate."
In the past year, the Barnet FC Supporters Trust has organised sponsored walks and recorded a song about the old stadium as part of Back 2 Barnet.
However, the campaign has gone quiet in recent months.
Mr Kleanthous added: "I have waited until after the local elections to see whether the Back 2 Barnet campaign would have any success and to give local supporters every opportunity to influence the councillors looking to get elected, but I have not seen much activity.
Promoted stories
"Ultimately we would all like to be in Barnet but this will require a concerted effort from a sizeable group of supporters. I'm not too sure whether enough have the appetite anymore."
In the early 2000s, there were plans for Barnet FC to move to the south part of the stadium, known as South Underhill, but these were ultimately rejected.
Mr Kleanthous said: "Despite the assertions of the conspiracy theorists amongst us, Barnet Council is not and has not been interested in anything to do with Barnet Football Club since Underhill ward become politically sensitive in the local elections 12 years ago.
"Contrary to the rubbish written on blogs and in the media, I do not support any political party and I have never provided any finance or gifts to any political party.
"My only sin was to fight the local council damn hard on the club's behalf and I have suffered a lot of cuts on the way, sometimes from our own camp.
"If the council wanted Barnet FC we would have been offered South Underhill ages ago. The only people that can make a difference and affect change in Barnet are all those who live and vote in Barnet."
Mr Kleanthous also denied money raised from the sale of Underhill would be used to pay for building at The Hive, which has all been financed by a cash injection of £7million provided by himself and grant money.
When asked how long Barnet FC was likely to be playing at The Hive, the chairman replied: "As long as is necessary until I can find a new site, preferably in Barnet, to build a modern new 10,000 seated stadium, which has always been my stated goal."
Leader of Barnet Council, Councillor Richard Cornelius, said: "I understand Tony Kleanthous is selling the Underhill ground. This is obviously separate from Barnet Football Club."
Promoted Stories
Barnet FC chairman Tony Kleanthous confirms club's plan to sell former Underhill Stadium after move to The Hive in Edgware
Oh dear. No Tory councillors left in Underhill to now fight the inevitable proccess of building on the ward's greenspaces....
Sooner or later Barnet will be just another Labour-led concrete jungle.
Oh dear. No Tory councillors left in Underhill to now fight the inevitable proccess of building on the ward's greenspaces....
Sooner or later Barnet will be just another Labour-led concrete jungle.
while the tories had councillors in the ward, one was busy drinking & driving, and the other was busy doing nothing.
while the tories had councillors in the ward, one was busy drinking & driving, and the other was busy doing nothing.


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Dan Wegendt | posted Feb 6th 2014
While discussing the recent weather related closings, Mark Sweetwood and Bertram de Souza reminisce over their childhood hardships.
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sqlninja v0.2.5 Released – Microsoft SQL Server (MS-SQL) SQL Injection Vulnerability Tool
It's been 2 years, but a new version of sqlninja is out at Sourceforge, we wrote about the previous release back in 2008 and we've actually been following this tool since 2006!
Sqlninja is a tool to exploit SQL Injection vulnerabilities on a web application that uses Microsoft SQL Server as its back-end. Its main goal is to provide an interactive access on the vulnerable DB server, even in a very hostile environment. It should be used by penetration testers to help and automate the process of taking over a DB Server when a SQL Injection vulnerability has been discovered.
- Fingerprint of the remote SQL Server (version, user performing the queries, user privileges, xp_cmdshell availability, DB authentication mode)
- Bruteforce of 'sa' password (in 2 flavors: dictionary-based and incremental)
- Privilege escalation to sysadmin group if 'sa' password has been found
- Creation of a custom xp_cmdshell if the original one has been removed
- Upload of netcat (or any other executable) using only normal HTTP requests (no FTP/TFTP needed)
- TCP/UDP portscan from the target SQL Server to the attacking machine, in order to find a port that is allowed by the firewall of the target network and use it for a reverse shell
- Direct and reverse bindshell, both TCP and UDP
- DNS-tunneled pseudo-shell, when no TCP/UDP ports are available for a direct/reverse shell, but the DB server can resolve external hostnames
- Evasion techniques to confuse a few IDS/IPS/WAF
- Integration with Metasploit3, to obtain a graphical access to the remote DB server through a VNC server injection
What's New?
- Proxy support (it was about time!)
- No more 64k bytes limit in upload mode
- Upload mode is also massively faster
- Privilege escalation through token kidnapping (kudos to Cesar Cerrudo)
- Other minor improvements
It is written in Perl, it is released under the GPLv2 and so far has been successfully tested on:
- Linux
- FreeBSD
- Mac OS X
You can download sqlninja v0.2.5 here:
Or read more here.
- Onapsis Bizploit v1.50 – SAP Penetration Testing Framework
- OAT – Oracle Auditing Tools For Database Security
- ODAT (Oracle Database Attacking Tool) – Test Oracle Database Security
Related Posts:
- sqlninja 0.2.3 released – Advanced Automated SQL Injection Tool for MS-SQL
- sqlninja 0.2.2 Released for Download – SQL Injection Tool
- sqlninja 0.1.2 Released for Download – SQL Injection Tool
Most Read in Database Hacking:
- Pangolin – Automatic SQL Injection Tool - 75,424 views
- bsqlbf 1.1 – Blind SQL Injection Tool - 54,160 views
- SQLBrute – SQL Injection Brute Force Tool - 40,004 views


text:
Results 1 to 1 of 1
Thread: Waiting till next year again
-12-24-2005 #1LaRamsFanLongTime Guest
Waiting till next year again
All I wanted was to beat those whiners, Oh well. Truly disgusting losing at home to the worst team in the NFL . Maybe they were playing for a better pick who knows terrible, terrible, teribble.


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Crack House 01 by tatehemlockWatch
©2009-2016 tatehemlock
Cheyenne in the crack house in Casa Grande, AZ the first time we shot together back in Nove 2007. This is right before I wrapped her in red ribbons LOL
I love that corset.
Lovely stuff. I'm really digging this girl's style!
Red ribbons huh , I'm going to have to find that one !!!!!! This is AWESOME , full of personality !!!!!! Now I'm trying to picture her 2 years more Beautiful !!!!!!
It's in my port somewhere
i love the nature atmosphere in this shot ... very simple
i like this shot, cute girl =]
keep it up ~
i like this shot, cute girl =]
keep it up ~
pretty shot


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Ok so I had another lesson today! :) (yay) and I did rather well, especially at the canter, but at the trot my legs are moving sooo much!
I will post a video once it finishes loading, but any advice on how to keep it motionless? I read somewhere you're leg will move a lot if you post by lifting yourself with your stirrups instead of... ??????
So ya I have to put less weight at the ball of my feet to lift me and more, ... like I have to lift myself by tightening my knees??
Ya... so basically what I am asking... is how am I suppose to post?


text:
- 3Promote
Framed Art Print
Green Ladiesby Gala98
Choose from a variety of frame styles, colors and sizes to compliment your favorite Society6 gallery, or fine art print - made ready to hang. Fine-crafted from solid woods, premium shatterproof acrylic protects the face of the art print, while an acid free dust cover on the back provides a custom finish. All framed art prints include wall hanging hardware.
Three moss covered ladies water feature at a health spa somewhere in Thailand


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Currently many phones have accelerometers that can be used for determining pitch, roll and yaw. The newest phones have a "gyroscope", which is like the accelerometers, but are better at determining the acceleration of your phone, but also provide other
For an explanation of what a solid state gyroscope does, take a look at the IEEE paper at:
The article was written in 2003, but gives a fairly accurate picture of the way a "solid state" gyro works and it is brief.
If you want to go through the process of using a gyro chip in an embedded system, you would want to take a look at the Accelerometer and Gyro Tutorial:
Learn what a Kalman filter is (this is an important piece of knowledge for working with gyroscopes):
Legal Note:


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Pneumocystis Pneumonia in Hospitalized Patients; A Detailed Examination of Symptoms, Management, and Outcomes in HIV-infected and HIV-uninfected Persons
McKinnell, James A.
Cannella, Anthony P.
Kunz, Danielle F.
Hook, Edward W.
Moser, Stephen A.
Miller, Loren G.
Baddley, John W.
Pappas, Peter G.
Transplant infectious disease : an official journal of the Transplantation Society
Pneumocystis jiroveci pneumonia is a life-threatening infection for immunocompromised individuals. There are robust data and clear guidelines for prophylaxis and treatment of HIV-related Pneumocystis jiroveci pneumonia (HIV-PCP), yet few data and no guidelines for non-HIV related Pneumocystis pneumonia (NH-PCP). We postulated that prevention and inpatient management of HIV-PCP differed from NH-PCP.
We performed a retrospective case review of all pathologically confirmed cases of PCP seen at the University of Alabama Medical Center from 1996 to 2008. Data on clinical presentation, hospital course, and outcome were collected using a standardized data collection instrument. Bivariate analysis compared prophylaxis, adjunctive corticosteroids, and clinical outcomes between patients with HIV-PCP and NH-PCP.
Our analysis of the cohort included 97 cases of PCP; 65 HIV and 32 non-HIV cases. Non-HIV cases rarely received primary prophylaxis (4% vs. 38%, p=0.01) and received appropriate antibiotics later in the course of hospitalization (5.2 vs 1.1 days, P<0.005). Among transplant patients, NH-PCP was diagnosed a mean of 1,066 days after transplantation and most patients were on low-dose corticosteroids (87%) at the time of disease onset. No significant differences in adjunctive corticosteroid use (69% vs. 77%, p=0.39) and 90-day mortality (41% vs. 28%, p=0.20) were detected.
Patients who have undergone organ or stem cell transplant remain at risk for PCP for many years after transplantation. In our cohort, patients who developed NH-PCP were rarely given prophylaxis and initiation of appropriate antibiotics was significantly delayed compared to cases of HIV-PCP. Medical providers should be aware of the ongoing risk for NH-PCP, even late after transplantation, and consider more aggressive approaches to both prophylaxis and earlier empiric therapy for PCP.
Pneumocystis Pneumonia; Transplant; Infectious Complications
Related Articles
Early Predictors of Mortality from Pneumocystis jirovecii Pneumonia in HIV-Infected Patients: 1985–2006
Walzer, Peter D.
Evans, Hannah E. R.
Copas, Andrew J.
Edwards, Simon G.
Grant, Alison D.
Miller, Robert F.
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
Pneumocystis jirovecii pneumonia (PCP) remains the leading cause of opportunistic infection among human immunodeficiency virus (HIV)–infected persons. Previous studies of PCP that identified case-fatality risk factors involved small numbers of patients, were performed over few years, and often focused on patients who were admitted to the intensive care unit.
The objective of this study was to identify case-fatality risk factors present at or soon after hospitalization among adult HIV-infected patients admitted to University College London Hospitals (London, United Kingdom) from June 1985 through June 2006.
Patients and Methods
We performed a review of case notes for 494 consecutive patients with 547 episodes of laboratory-confirmed PCP.
Overall mortality was 13.5%. Mortality was 10.1% for the period from 1985 through 1989, 16.9% for the period from 1990 through June 1996, and 9.7% for the period from July 1996 through 2006 (P = .142). Multivariate analysis identified factors associated with risk of death, including increasing patient age (adjusted odds ratio [AOR], 1.54; 95% confidence interval [CI], 1.11–2.23; P = .011), subsequent episode of PCP (AOR, 2.27; 95% CI, 1.14–4.52; P = .019), low hemoglobin level at hospital admission (AOR, 0.70; 95% CI, 0.60–0.83; P < .001), low partial pressure of oxygen breathing room air at hospital admission (AOR, 0.70; 95% CI, 0.60–0.81; P < .001), presence of medical comorbidity (AOR, 3.93; 95% CI, 1.77–8.72; P = .001), and pulmonary Kaposi sarcoma (AOR, 6.95; 95% CI, 2.26–21.37; P =.001). Patients with a first episode of PCP were sicker (mean partial pressure of oxygen at admission ± standard deviation, 9.3 ± 2.0 kPa) than those with a second or third episode of PCP (mean partial pressure of oxygen at admission ± standard deviation, 9.9 ± 1.9 kPa; P =.008), but mortality among patients with a first episode of PCP (12.5%) was lower than mortality among patients with subsequent episodes of PCP (22.5%) (P = .019). No patient was receiving highly active antiretroviral therapy before presentation with PCP, and none began highly active antiretroviral therapy during treatment of PCP.
Mortality risk factors for PCP were identifiable at or soon after hospitalization. The trend towards improved outcome after June 1996 occurred in the absence of highly active antiretroviral therapy.
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Environmental Risk Factors for Pneumocystis Pneumonia Hospitalizations in HIV Patients
Djawe, Kpandja
Levin, Linda
Swartzman, Alexandra
Fong, Serena
Roth, Brenna
Subramanian, Anuradha
Grieco, Katherine
Jarlsberg, Leah
Miller, Robert F.
Huang, Laurence
Walzer, Peter D.
Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America
This report identifies both climatological and air pollution constituents as independent risk factors for hospitalization of HIV-positive patients with Pneumocystis pneumonia (PcP). These findings may lead to new insights about the epidemiology and pathogenesis of PcP.
Background. Pneumocystis pneumonia (PcP) is the second leading cause of morbidity and mortality in human immunodeficiency virus (HIV)–infected patients in the United States. Although the host risk factors for the development of PcP are well established, the environmental (climatological, air pollution) risk factors are poorly understood. The major goal of this study was to determine the environmental risk factors for admissions of HIV-positive patients with PcP to a single medical center.
Methods. Between 1997 and 2008, 457 HIV-positive patients with microscopically confirmed PcP were admitted to the San Francisco General Hospital. A case-crossover design was applied to identify environmental risk factors for PcP hospitalizations. Climatological and air pollution data were collected from the Environmental Protection Agency and Weather Warehouse databases. Conditional logistic regression was used to evaluate the association of each environmental factor and PcP hospital admission.
Results. Hospital admissions were significantly more common in the summer than in the other seasons. Increases in temperature and sulfur dioxide levels were independently associated with hospital admissions for PcP, but the effects of sulfur dioxide were modified by increasing carbon monoxide levels.
Conclusions. This study identifies both climatological and air pollution constituents as independent risk factors for hospitalization of HIV-positive patients with PcP in San Francisco. Thus, the environmental effects on PcP are more likely complex than previously thought. Further studies are needed to understand how these factors exert their effects and to determine if these factors are associated with PcP in other geographic locations.
Pneumocystis; PcP; environmental factors; HIV
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Pneumocystis pneumonia in South African children diagnosed by molecular methods
Morrow, Brenda M
Samuel, Catherine M
Zampoli, Marco
Whitelaw, Andrew
Zar, Heather J
BMC Research Notes
Pneumocystis pneumonia (PCP) is an important cause of hospitalization and mortality in HIV-infected children. However, the incidence of PCP has been underestimated due to poor sensitivity of diagnostic tests. The use of polymerase chain reaction (PCR) for pneumocystis has enabled more reliable diagnosis. This study describes the incidence, clinical features and outcome of PCP in South African children diagnosed using PCR.
A prospective study of children hospitalised in South Africa with suspected PCP was done from November 2006 to August 2008. Clinical, laboratory and radiological information were collected. Lower respiratory tract specimens were obtained for PCP immunofluorescence (IF), real- time PCR for pneumocystis, bacterial and mycobacterial culture. Nasopharyngeal aspirates were taken for immunofluorescence (IF), real-time PCR for pneumocystis and PCR for respiratory viruses. A blood specimen for bacterial culture and for cytomegalovirus PCR was taken. Children were followed for the duration of their hospitalisation and the outcome was recorded.
202 children [median (interquartile range, IQR) age 3.2 (2.1– 4.6) months] were enrolled; 124 (61.4%) were HIV infected. PCP was identified in 109 (54%) children using PCR, compared to 43 (21%) using IF and Grocott staining (p < 0.0001). Most PCP cases (88, 81%) occurred in HIV-infected children. All 21 cases (19%) occurring in HIV- negative children had another risk factor for PCP. On logistic regression, predictive factors for PCP were HIV infection, lack of fever, high respiratory rate and low oxygen saturation whilst cotrimoxazole prophylaxis was protective (OR 0.24; 95% CI 0.1 to 0.5; p < 0.002). The case fatality of children with PCP was higher than those without PCP (32.1% versus 17.2%; relative risk 1.87; 95% confidence interval (CI) 1.11 – 3.15). Amongst HIV-infected children, a CD4 less than 15% was the only independent predictor of mortality.
The diagnostic yield for PCP is more than 2.5 times higher on PCR than other detection methods. PCP is a very common cause of severe hypoxic pneumonia and is associated with high mortality in HIV-infected African infants.
Pneumocystis pneumonia; HIV; Children; Prophylaxis; PCR; Diagnosis; Incidence
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Comparison of community-acquired pneumonia requiring admission to hospital in HIV-and non-HIV-infected patients
Touchie, Claire
Marrie, Thomas J
The Canadian Journal of Infectious Diseases
To compare community-acquired pneumonia (CAP) in hospitalized human immunodeficiency virus (HIV)-infected patients with that in hospitalized non-HIV-infected patients by assessing presenting characteristics, etiology and outcomes.
Retrospective chart review.
A tertiary care centre in Halifax, Nova Scotia.
Thirty-two HIV-infected patients requiring hospitalization for treatment of CAP were identified from September 1991 to October 1993 and compared with 33 age-matched non-HIV-infected patients who presented with pneumonia during the same period.
The two populations were comparable in age, sex and race. Fifty per cent of the HIV-infected and 20.8% of the non-HIV-infected patients had had a previous episode of pneumonia. Pneumocystis carinii pneumonia (PCP) accounted for 16 of the 32 episodes of CAP in the HIV-infected patients, while none of the non-HIV-infected patients had PCP. Pneumonia secondary to Streptococcus pneumoniae was more common in the non-HIV-infected patients (five versus one, P=0.02). Vital signs and initial PO2 did not differ between the two groups. White blood cell count was lower at admission for the HIV population (5.7×109/L versus 12.7×109/L, P=0.003). The HIV patients were more likely to undergo bronchoscopy (27.7% versus 0%, P<0.001). The length of stay in hospital, transfer to the intensive care unit and necessity for intubation were the same for both groups. The in-hospital mortality for HIV-infected patients was eight of 32 (25%) while for the non-HIV-infected patients it was none of 33 (P=0.002).
Patients with HIV infection who present with CAP are more likely to have PCP, to have had a past episode of pneumonia and to die while in hospital than age- and sex-matched non-HIV-infected patients with CAP.
Community-acquired pneumonia; Human immunodeficiency virus infection; Hospitalization
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Improved survival for HIV infected patients with severe Pneumocystis jirovecii pneumonia is independent of highly active antiretroviral therapy
Miller, R F
Allen, E
Copas, A
Singer, M
Edwards, S G
Despite a decline in incidence of Pneumocystis jirovecii pneumonia (PCP), severe PCP continues to be a common cause of admission to the intensive care unit (ICU) where mortality remains high. A study was undertaken to examine the outcome from intensive care for patients with PCP and to identify prognostic factors.
A retrospective cohort study was conducted of HIV infected adults admitted to a university affiliated hospital ICU between November 1990 and October 2005. Case note review collected information on demographic variables, use of prophylaxis and highly active antiretroviral therapy (HAART), and hospital course. The main outcome was 1 month mortality, either on the ICU or in hospital.
Fifty nine patients were admitted to the ICU on 60 occasions. Thirty four patients (57%) required mechanical ventilation. Overall mortality was 53%. No patient received HAART before or during ICU admission. Multivariate analysis showed that the factors associated with mortality were the year of diagnosis (before mid 1996 (mortality 71%) compared with later (mortality 34%; p = 0.008)), age (p = 0.016), and the need for mechanical ventilation and/or development of pneumothorax (p = 0.031). Mortality was not associated with sex, ethnicity, prior receipt of sulpha prophylaxis, haemoglobin, serum albumin, CD4 count, Pao2, A‐ao2 gradient, co‐pathology in bronchoscopic lavage fluid, medical co‐morbidity, APACHE II score, or duration of mechanical ventilation.
Observed improved outcomes from severe PCP for patients admitted to the ICU occurred in the absence of intervention with HAART and probably reflect general improvements in ICU management of respiratory failure and ARDS rather than improvements in the management of PCP.
AIDS; intensive care; mechanical ventilation; Pneumocystis jirovecii ; opportunistic infections; respiratory failure
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Non-HIV Pneumocystis pneumonia: do conventional community-acquired pneumonia guidelines under estimate its severity?
Asai, Nobuhiro
Motojima, Shinji
Ohkuni, Yoshihiro
Matsunuma, Ryo
Nakasima, Kei
Iwasaki, Takuya
Nakashita, Tamao
Otsuka, Yoshihito
Kaneko, Norihiro
Multidisciplinary Respiratory Medicine
Non-HIV Pneumocystis pneumonia (PCP) can occur in immunosuppressed patients having malignancy or on immunosuppressive agents. To classify severity, the A-DROP scale proposed by the Japanese Respiratory Society (JRS), the CURB-65 score of the British Respiratory Society (BTS) and the Pneumonia Severity Index (PSI) of the Infectious Diseases Society of America (IDSA) are widely used in patients with community-acquired pneumonia (CAP) in Japan. To evaluate how correctly these conventional prognostic guidelines for CAP reflect the severity of non-HIV PCP, we retrospectively analyzed 21 patients with non-HIV PCP.
A total of 21 patients were diagnosed by conventional staining and polymerase chain reaction (PCR) for respiratory samples with chest x-ray and computed tomography (CT) findings. We compared the severity of 21 patients with PCP classified by A-DROP, CURB-65, and PSI. Also, patients' characteristics, clinical pictures, laboratory results at first visit or admission and intervals from diagnosis to start of specific-PCP therapy were evaluated in both survivor and non-survivor groups.
Based on A-DROP, 18 patients were classified as mild or moderate; respiratory failure developed in 15 of these 18 (83.3%), and 7/15 (46.7%) died. Based on CURB-65, 19 patients were classified as mild or moderate; respiratory failure developed in 16/19 (84.2%), and 8 of the 16 (50%) died. In contrast, PSI classified 14 as severe or extremely severe; all of the 14 (100%) developed respiratory failure and 8/14 (57.1%) died. There were no significant differences in laboratory results in these groups. The time between the initial visit and diagnosis, and the time between the initial visit and starting of specific-PCP therapy were statistically shorter in the survivor group than in the non-survivor group.
Conventional prognostic guidelines for CAP could underestimate the severity of non-HIV PCP, resulting in a therapeutic delay resulting in high mortality. The most important factor to improve the mortality of non-HIV PCP is early diagnosis and starting of specific-PCP therapy as soon as possible.
Community acquired pneumonia; Guidelines; Mortality; Non-HIV Pneumocystis pneumonia
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Critical care management and outcome of severe Pneumocystis pneumonia in patients with and without HIV infection
Monnet, Xavier
Vidal-Petiot, Emmanuelle
Osman, David
Hamzaoui, Olfa
Durrbach, Antoine
Goujard, Cécile
Miceli, Corinne
Bourée, Patrice
Richard, Christian
Critical Care
Little is known about the most severe forms of Pneumocystis jiroveci pneumonia (PCP) in HIV-negative as compared with HIV-positive patients. Improved knowledge about the differential characteristics and management modalities could guide treatment based on HIV status.
We retrospectively compared 72 patients (73 cases, 46 HIV-positive) admitted for PCP from 1993 to 2006 in the intensive care unit (ICU) of a university hospital.
The yearly incidence of ICU admissions for PCP in HIV-negative patients increased from 1993 (0%) to 2006 (6.5%). At admission, all but one non-HIV patient were receiving corticosteroids. Twenty-three (85%) HIV-negative patients were receiving an additional immunosuppressive treatment. At admission, HIV-negative patients were significantly older than HIV-positive patients (64 [18 to 82] versus 37 [28 to 56] years old) and had a significantly higher Simplified Acute Physiology Score (SAPS) II (38 [13 to 90] versus 27 [11 to 112]) but had a similar PaO2/FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio (160 [61 to 322] versus 183 [38 to 380] mm Hg). Ventilatory support was required in a similar proportion of HIV-negative and HIV-positive cases (78% versus 61%), with a similar proportion of first-line non-invasive ventilation (NIV) (67% versus 54%). NIV failed in 71% of HIV-negative and in 13% of HIV-positive patients (p < 0.01). Mortality was significantly higher in HIV-negative than HIV-positive cases (48% versus 17%). The HIV-negative status (odds ratio 3.73, 95% confidence interval 1.10 to 12.60) and SAPS II (odds ratio 1.07, 95% confidence interval 1.02 to 1.12) were independently associated with mortality at multivariate analysis.
The yearly incidence of ICU admissions for PCP in HIV-negative patients in our unit increased from 1993 to 2006. The course of the disease and the outcome were worse in HIV-negative patients. NIV often failed in HIV-negative cases, suggesting that NIV must be watched closely in this population.
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Impact of haart on causes of death of persons with late-stage AIDS
Sansone, Giorgio R.
Dermot Frengley, J.
Journal of Urban Health : Bulletin of the New York Academy of Medicine
The increasing use of highly active antiretroviral therapies (HAARTs) has changed the course of AIDS-related illnesses and enhanced the quality of life of patients infected with human immunodeficiency virus (HIV) and may have changes the causes of deaths in patients with acquired immunodeficiency syndrome (AIDS).
The aim of the present study was to investigate causes of deaths in long-term care hospital patients with late-stage AIDS who expired at the Coler-Goldwater Memorial Hospital in New York City in 1995, and in 1998 and 1999, that is, immediately before and the two most recent years after the advent of HAART.
Analysis of causes of deaths as recorded on the death certificates of 232 AIDS patients.
The overall mortality rate declined from 75.6 deaths per 100 person-years in 1995 to 33.2 deaths per 100 person-years in 1998–1999 (P<.001) The number of AIDS patients who expired because of sepsis and opportunistic infections, which includedPneumocystis carinii Pneumonia (PCP), decreased significantly from 30 (26.1%) and 24 (20.9%) in 1995 to 15 (12.8%) and 10 (8.5%) in 1998–1999, respectively (P<.05). In contrast, deaths from hepatic failure increased from 0(0%) in 1995 to 7 (6%) in 1998–1999 (P<.05). Increases, although not significant statistically, were associated with pneumonias excluding PCP, end-stage AIDS, renal failure, and malignancies. Analysis of cause-specific mortality by gender between 1995 and 1998–1999 revealed very little difference between men and women. This analysis showed, however, that the infectious processes taken together (pneumonias excluding PCP, sepsis, and opportunistic infections including PCP) were significantly less frequent causes of death in 1998–1999 than in 1995 (P<.01).
These findings indicate that HAART affected the causes of deaths in patients with AIDS, with "traditional" opportunistic infections diminishing in importance relative to chronic medical conditions and malignancies.
Death; HAART; Hepatic Failure; Late-Stage AIDS; Opportunistic Infections; Sepsis
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Prognostic factors influencing the outcome in pneumocystis carinii pneumonia in patients with AIDS.
Fernandez, P.
Torres, A.
Miro, J. M.
Vieigas, C.
Mallolas, J.
Zamora, L.
Gatell, J. M.
Valls, M. E.
Riquelme, R.
Rodríguez-Roisin, R.
BACKGROUND--Studies attempting to identify the prognostic factors that influence the outcome of Pneumocystis carinii pneumonia (PCP) in patients with AIDS using a multivariate analysis are few. In order to identify those prognostic factors amenable to medical intervention, univariate and multivariate analyses were performed on 102 patients with AIDS suffering a first episode of PCP. METHODS--One hundred and two consecutive patients with AIDS (51% drug abusers, 45% homosexuals, and 4% with other HIV risk factors) admitted to our institution between 1986 and 1989 whose respiratory infection was diagnosed by bronchoalveolar lavage were studied prospectively. RESULTS--The overall mortality was 28%, rising to 79% in those patients who required mechanical ventilation. According to univariate analysis the following variables were related to a poor prognosis: age > 35 years; risk factor for HIV infection other than drug abuse; and AIDS diagnosis confirmed before 1988; PaO2 < 8 kPa at admission; severe acute respiratory failure on admission (PaO2/FIO2 < 20 kPa); mechanical ventilation; antibiotic therapy for PCP other than trimethoprim-sulphamethoxazole; multiple microbial pulmonary infection; serum lactate dehydrogenase (LDH) > 22.5 mukat/l on admission; serum albumin level < 30 g/l. Multivariate analysis showed that only mechanical ventilation was independently associated with a poor outcome. CONCLUSIONS--The mortality of AIDS patients presenting with a first episode of PCP before 1990 was high (28%). The main prognostic factor associated with poor outcome was the requirement for mechanical ventilation due to severe acute respiratory failure.
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Outcome of HIV-associated Pneumocystis pneumonia in hospitalized patients from 2000 through 2003
Radhi, Saba
Alexander, Travis
Ukwu, Michelle
Saleh, Samer
Morris, Alison
BMC Infectious Diseases
Pneumocystis pneumonia (PCP) remains a leading cause of morbidity and mortality in HIV-infected persons. Epidemiology of PCP in the recent era of highly active antiretroviral therapy (HAART) is not well known and the impact of HAART on outcome of PCP has been debated.
To determine the epidemiology of PCP in HIV-infected patients and examine the impact of HAART on PCP outcome.
We performed a retrospective cohort study of 262 patients diagnosed with PCP between January 2000 and December 2003 at a county hospital at an academic medical center. Death while in the hospital was the main outcome measure. Multivariate modeling was performed to determine predictors of mortality.
Overall hospital mortality was 11.6%. Mortality in patients requiring intensive care was 29.0%. The need for mechanical ventilation, development of a pneumothorax, and low serum albumin were independent predictors of increased mortality. One hundred and seven patients received HAART before hospitalization and 16 patients were started on HAART while in the hospital. HAART use either before or during hospitalization was not associated with mortality.
Overall hospital mortality and mortality predictors are similar to those reported earlier in the HAART era. PCP diagnoses in HAART users likely represented failing HAART regimens or non-compliance with HAART.
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Patient-Centered Research Abstracts
Swenson, SL
Shapiro, S
Cunningham, C
Gourevitch, M
Journal of General Internal Medicine
2000;15(Suppl 2):6-7.
AIDS continues to devastate urban communities, particularly among marginally-housed, ethnic minority, and drug-using populations. This study (1) describes access to comprehensive medical care, quality of HIV-related care, and attitudes regarding health among HIV-infected residents of single-room occupancy (SRO) hotels and (2) explores predictors of the use of pneumocystis carinii pneumonia (PCP) prophylaxis and highly-active antiretroviral therapy (HAART).
We conducted a cross-sectional, community-based study of 69 Bronx SRO hotel residents during May 1998. Utilizing door-to-door recruitment, we administered a 41-item, anonymous questionnaire to assess participants' demographic characteristics, level of illness and health care utilization, use of HIV-related therapies, and perceptions of their own health and medical care.
Of respondents, 65% identified as African-American or Black, 22% as Puerto Rican, and 13% as White or Other. The median age was 42; 68% were male, and 38% were high school graduates. Most individuals were marginally-housed (median stay = 9 months). Almost all participants (96%) paid for medical services via Medicaid. Of the 93% with HIV infection, 44% had been hospitalized at least once in the past year, 72% reported a history of AIDS-defining opportunistic infections, and the median CD4 count was 214. Over two-thirds were actively using drugs and/or alcohol.
Among HIV-infected residents, 81% had seen a doctor in the last three months. However, only 67% felt they had a "regular" physician, and 48% felt their access to medical care was average to very poor. Among eligible HIV-infected persons, only 39% had taken HAART and 73% had taken PCP prophylaxis in the last week. Predictors for the use of HAART included absence of active cocaine and/or crack use (RR = 3.91; 95% CI 1.03–14.8; p < .03), use of PCP prophylaxis (RR = 5.69; 95% CI .85–38.1; p < .03) and the belief that HAART "can help people with AIDS" (RR = 1.75; 95% CI 1.28–2.44; p < .03). HAART use did not correlate with site or frequency of medical care or active alcohol or heroin use. Individuals with regular doctors were less likely to have visited an emergency room in the past 3 months (RR = .41; 95% CI .22–.76; p < .02) and more likely to be taking PCP prophylaxis (RR = 2.68; 95% CI 1.19–6.02; p < .008).
Despite relatively advanced disease in this population of marginally-housed HIV-infected persons, significant proportions do not have a regular primary care provider, are not taking HAART, and report sub-optimal quality of and access to medical care. Active cocaine and/or crack use correlate with a lesser use of HAART.
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Severity and outcomes of Pneumocystis pneumonia in patients newly diagnosed with HIV infection: an observational cohort study
Fei, Matthew W.
Sant, Catherine A.
Kim, Eunice J.
Swartzman, Alexandra
Davis, J. Lucian
Jarlsberg, Leah G.
Huang, Laurence
Scandinavian journal of infectious diseases
It is unclear whether patients who are unaware of their HIV infection have different severity or outcomes of Pneumocystis pneumonia (PCP) compared to patients who have been previously diagnosed with HIV. In this retrospective observational cohort study of consecutive HIV-infected patients with microscopically diagnosed PCP at San Francisco General Hospital between 1997 and 2006, 121 of 522 patients (23%) were unaware of their HIV infection prior to their diagnosis of PCP. The proportion of patients with concurrently diagnosed HIV and PCP each year remained unchanged during the study period. Patients with newly diagnosed HIV had a significantly higher alveolar-arterial oxygen gradient at presentation (median 51 versus 45 mm Hg, p=0.03), but there were no differences in mortality, frequency of mechanical ventilation, or admission to intensive care compared to patients with previously diagnosed HIV infection. In multivariate analysis, patients who reported a sexual risk factor for HIV infection were more likely to be newly diagnosed with HIV than patients who reported injection drug use as their only HIV risk factor (odds ratio = 3.14, 95% confidence interval 1.59–6.18, p = 0.001). This study demonstrates a continued need for HIV education and earlier HIV testing, particularly in patients with high-risk sexual behavior.
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Predicting mortality from HIV-associated Pneumocystis pneumonia at illness presentation: an observational cohort study
Fei, Matthew W.
Kim, Eunice J.
Sant, Catherine A.
Jarlsberg, Leah G.
Davis, J. Lucian
Swartzman, Alexandra
Huang, Laurence
Although the use of antiretroviral therapy has led to dramatic declines in AIDS-associated mortality, Pneumocystis pneumonia (PCP) remains a leading cause of death in HIV-infected patients.
To measure mortality, identify predictors of mortality at time of illness presentation, and derive a PCP mortality prediction rule that stratifies patients by risk for mortality.
Observational cohort study with case note review of all HIV-infected persons with a laboratory diagnosis of PCP at San Francisco General Hospital from 1997–2006.
451 patients were diagnosed with PCP on 524 occasions. In-hospital mortality was 10.3%. Multivariate analysis identified five significant predictors of mortality: age (adjusted odds ratio [AOR] per 10-year increase, 1.69; 95% confidence interval [CI] 1.08–2.65; p=0.02); recent injection drug use (AOR 2.86; 95% CI 1.28–6.42; p=0.01); total bilirubin >0.6 mg/dL (AOR 2.59; 95% CI 1.19–5.62; p=0.02); serum albumin <3 g/dL (AOR 3.63; 95% CI 1.72–7.66; p=0.001); and alveolar-arterial oxygen gradient ≥50 mm Hg (AOR 3.02; 95% CI 1.41–6.47; p=0.004). Using these five predictors, we derived a six point PCP mortality prediction rule that stratifies patients according to increasing risk of mortality: score 0–1, 4%; score 2–3, 12%; score 4–5, 48%.
Our PCP mortality prediction rule stratifies patients by mortality risk at the time of illness presentation and should be validated as a clinical tool.
Pneumonia; Pneumocystis; HIV/AIDS; antiretroviral therapy; highly active
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Spectrums of Opportunistic Infections and Malignancies in HIV-Infected Patients in Tertiary Care Hospital, China
Xiao, Jiang
Gao, Guiju
Li, Yanmei
Zhang, Wen
Tian, Yunfei
Huang, Yinxiu
Su, Wenjing
Han, Ning
Yang, Di
Zhao, Hongxin
PLoS ONE
HIV-related opportunistic infections (OIs) and malignancies continued to cause morbidity and mortality in Chinese HIV-infected individuals. The objective for this study is to elucidate the prevalence and spectrums of OIs and malignancies in HIV-infected patients in the Beijing Ditan Hospital.
The evaluation of the prevalence and spectrums of OIs and malignancies was conducted by using the clinical data of 834 HIV-infected patients admitted in the Beijing Ditan hospital from January 1, 2009, to November 30, 2012.
The prevalence and spectrums of OIs and malignancies varied contingent on geographic region, transmission routes, and CD4 levels. We found that tuberculosis was most common OI and prevalence was 32.5%, followed by candidiasis(29.3%), Pneumocystis pneumonia(PCP)(22.4%), cytomegalovirus(CMV) infection(21.7%), other fungal infections(16.2%), mycobacterium avium complex(MAC)(11.3%), cryptococcosis(8.0%), progressive multifocal leukoencephalopathy(PML)(4.4%), Cerebral Toxoplasmosis(3.5%) and Penicillium marneffei infection(1.4%); while Lymphoma(2.9%), Kaposi's sarcoma(0.8%) and cervix carcinoma(0.3%) were emerged as common AIDS-defining malignancies. Pulmonary OI infections were the most prevalent morbidity and mortality in patients in the AIDS stage including pulmonary tuberculosis (26.6%) and PCP (22.4%). CMV infection(21.7%) was most common viral infection; Fungal OIs were one of most prevalent morbidity in patients in the AIDS stage, including oral candidiasis (29.3%), other fungal infection (16.2%), Cryptococcosis (8.0%) and Penicillium marneffei infection (1.4%). We found the low prevalence of AIDS-defining illnesses in central neural system in this study, including progressive multifocal leukoencephalopathy (4.4%), cerebral toxoplasmosis (3.5%), tuberculosis meningitis (3.2%), cryptococcal meningitis (2.4%) and CMV encephalitis (1.1%). In-hospital mortality rate was 4.3 per 100 person-years due to severe OIs, malignancies, and medical cost constraints.
The prevalence and spectrums of OIs, malignancies and co-infections were discussed in this study. It would help increase the awareness for physicians to make a diagnosis and empirical treatment sooner and plan good management strategies, especially in resource limited regions.
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Pneumocystis Pneumonia in HIV-Infected and Immunocompromised Non-HIV Infected Patients: A Retrospective Study of Two Centers in China
Guo, Fei
Chen, Yong
Yang, Shuang-Li
Xia, Huan
Li, Xing-Wang
Tong, Zhao-Hui
PLoS ONE
Pneumocystis pneumonia (PCP) is an emerging infectious disease in immunocompromised hosts. However, the clinical characteristics of these patients are poorly understood in mainland China.
We performed a retrospective study of PCP from 2008 to 2012. Information was collected regarding clinical manifestations, hospitalization, and outcome. A prognostic analysis was performed using a Cox regression model.
151 cases of PCP were included; 46 non-HIV and 105 HIV cases. All-cause mortality (15.2% vs. 12.4%, p = 0.64) and the results of time-to-event analysis (log-rank test, p = 0.62) were similar between non-HIV and HIV infected cases, respectively. From 2008 to 2012, time from admission to initial treatment in non-HIV infected PCP patients showed declining trend [median (range) 20 (9–44) vs. 12 (4–24) vs. 9 (2–23) vs. 7 (2–22) vs. 7 (1–14) days]. A similar trend was observed for all-cause mortality (33.3% vs. 20.0% vs.14.3% vs. 14.3% vs. 6.7%). Patients with four or more of the following clinical manifestations (cough, dyspnea, fever, chest pain, and weight loss) [adjusted HR (AHR) 29.06, 95% CI 2.13–396.36, P = 0.01] and admission to intensive care unit (ICU) [AHR 22.55, 95% CI 1.36–375.06, P = 0.03] were independently associated with all-cause mortality in non-HIV infected PCP patients. Variables associated with mortality in HIV infected PCP patients were admission to ICU (AHR 72.26, 95% CI 11.76–443.87, P<0.001) and albumin ≤30 g/L (AHR 9.93 95% CI 1.69–58.30, P = 0.01).
Upon admission comprehensive clinical assessment including assessment of four or more clinical manifestations (cough, dyspnea, fever, chest pain, and weight loss) in non-HIV infected PCP patients and albumin ≤30 g/L in HIV infected patients might improve prognosis.
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Humoral Immune Responses to Pneumocystis jirovecii Antigens in HIV-Infected and Uninfected Young Children with Pneumocystis Pneumonia
Djawe, Kpandja
Daly, Kieran R.
Levin, Linda
Zar, Heather J.
Walzer, Peter D.
PLoS ONE
Humoral immune responses in human immunodeficiency virus (HIV)-infected and uninfected children with Pneumocystis pneumonia (PcP) are poorly understood.
Consecutive children hospitalized with acute pneumonia, tachypnea, and hypoxia in South Africa were investigated for PcP, which was diagnosed by real-time polymerase chain reaction on lower respiratory tract specimens. Serum antibody responses to recombinant fragments of the carboxyl terminus of Pneumocystis jirovecii major surface glycoprotein (MsgC) were analyzed.
149 children were enrolled of whom 96 (64%) were HIV-infected. PcP occurred in 69 (72%) of HIV-infected and 14 (26%) of HIV-uninfected children. HIV-infected children with PcP had significantly decreased IgG antibodies to MsgC compared to HIV-infected patients without PcP, but had similar IgM antibodies. In contrast, HIV-uninfected children with PcP showed no change in IgG antibodies to MsgC, but had significantly increased IgM antibodies compared to HIV-uninfected children without PCP. Age was an independent predictor of high IgG antibodies, whereas PcP was a predictor of low IgG antibodies and high IgM antibodies. IgG and IgM antibody levels to the most closely related MsgC fragments were predictors of survival from PcP.
Young HIV-infected children with PcP have significantly impaired humoral immune responses to MsgC, whereas HIV-uninfected children with PcP can develop active humoral immune responses. The children also exhibit a complex relationship between specific host factors and antibody levels to MsgC fragments that may be related to survival from PcP.
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Changes in hospitalizations due to opportunistic infections, chronic conditions and other causes among HIV patients (1989–2011). A study in a HIV unit
Redondo Sanchez, C
Poza Cisneros, G
Galera Peñaranda, C
Ruiz, C
Hernandez, A
Cascales, A
Rodriguez, F
Oliva, J
Journal of the International AIDS Society
2012;15(Suppl 4):18089.
Reduction in mortality and morbidity in HIV patients due to the introduction of HAART have resulted in changes in patterns of hospital admissions.
To examine trends of HIV patients hospital admissions.
Design and method
Serial cross-sectional analysis of HIV-hospitalized patients from 1989 to 2011 in an HIV Care Unit. Each hospitalization was classified as major categories: opportunistic infections, other infections, drug-related admissions, chronic hepatopathy, AIDS and non-AIDS-related tumours and chronic medical conditions (COPD, diabetes) and as specific diagnosis: tuberculosis, PCP, CMV, bacterial pneumonia and others. We considered 4 periods of time: pre-HAART, 1989–1996; early HAART, 1997–2001; intermediate HAART, 2002–2006; and present HAART, 2007–2011.
We evaluated 2588 admissions. 20.7% of patients were unaware of HIV infection before first admission; this proportion did not change along the time (p=0.27). No previous outpatient follow-up was seen in 34.9% of patients. There were differences in diagnosis, mortality, age and mean inpatient stay time (Table 1) between the analyzed periods of time.OIHIV tumoursNon-HIV tumoursChronic diseasesMortalityMean ageMean hospital stayPneumoniaResp infectTBCCMVPCPPMLPre-HAART 682 adm.51.7%* 5.1%* 0.8%* 3.2%* 10.1%* 36.1* 23.9* 12.1%* 14.1%* 14.1%15%* 9.5%* 5.1%Early HAART 632 adm.34.5%4%2.2%9%4.6%38.417.2* 21.1%19.9%11.7%5%8.2%4.1%Intermediate HAART 613 adm.31.4%* 2.4%2.8%7.7%4.4%39.615.725.6%* 23.2%11.4%1.7%* 3.4%* 3%Present HAART 661 adm.21.8%* 0.8%* 4.1%* 15.9%* 3.8%* 42.9* 14.229.8%* 29.2%* 10.9%1.9%* 4.2%* 2.2%*p<0.05
(i) HAART and older age have changed the pattern of hospital admissions with a decrease of OI-related admissions and an increase of chronic diseases and non-AIDS-related tumours and with a decrease in mortality and length of inpatient stay. (ii) Proportion of patients with unknown HIV serostatus before admission has not changed along the time. (iii) Pneumonia, respiratory tract infection and tuberculosis were the more common causes of admission.
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Causes of Acute Hospitalization in Adolescence: Burden and Spectrum of HIV-Related Morbidity in a Country with an Early-Onset and Severe HIV Epidemic: A Prospective Survey
Ferrand, Rashida A.
Bandason, Tsitsi
Musvaire, Praise
Larke, Natasha
Nathoo, Kusum
Mujuru, Hilda
Ndhlovu, Chiratidzo E.
Munyati, Shungu
Cowan, Frances M.
Gibb, Diana M.
Corbett, Elizabeth L.
PLoS Medicine
Rashida Ferrand and colleagues show that HIV infection is the commonest cause of hospitalization among adolescents in a high HIV prevalence setting.
Survival to older childhood with untreated, vertically acquired HIV infection, which was previously considered extremely unusual, is increasingly well described. However, the overall impact on adolescent health in settings with high HIV seroprevalence has not previously been investigated.
Methods and Findings
Adolescents (aged 10–18 y) systematically recruited from acute admissions to the two public hospitals in Harare, Zimbabwe, answered a questionnaire and underwent standard investigations including HIV testing, with consent. Pre-set case-definitions defined cause of admission and underlying chronic conditions. Participation was 94%. 139 (46%) of 301 participants were HIV-positive (median age of diagnosis 12 y: interquartile range [IQR] 11–14 y), median CD4 count = 151; IQR 57–328 cells/µl), but only four (1.3%) were herpes simplex virus-2 (HSV-2) positive. Age (median 13 y: IQR 11–16 y) and sex (57% male) did not differ by HIV status, but HIV-infected participants were significantly more likely to be stunted (z-score<−2: 52% versus 23%, p<0.001), have pubertal delay (15% versus 2%, p<0.001), and be maternal orphans or have an HIV-infected mother (73% versus 17%, p<0.001). 69% of HIV-positive and 19% of HIV-negative admissions were for infections, most commonly tuberculosis and pneumonia. 84 (28%) participants had underlying heart, lung, or other chronic diseases. Case fatality rates were significantly higher for HIV-related admissions (22% versus 7%, p<0.001), and significantly associated with advanced HIV, pubertal immaturity, and chronic conditions.
HIV is the commonest cause of adolescent hospitalisation in Harare, mainly due to adult-spectrum opportunistic infections plus a high burden of chronic complications of paediatric HIV/AIDS. Low HSV-2 prevalence and high maternal orphanhood rates provide further evidence of long-term survival following mother-to-child transmission. Better recognition of this growing phenomenon is needed to promote earlier HIV diagnosis and care.
Please see later in the article for the Editors' Summary
Editors' Summary
Acquired immunodeficiency syndrome (AIDS) has killed more than 25 million people since 1981, and more than 30 million people are now infected with the human immunodeficiency virus (HIV) that causes AIDS. HIV destroys the cells in the immune system that normally provide protection against disease-causing organisms. Consequently, people infected with HIV are susceptible to so-called opportunistic infections, including tuberculosis and pneumonia. HIV is most commonly spread through unprotected sex with an infected partner but another major route of transmission is mother-to-child (vertical transmission) during pregnancy or delivery or during breast feeding. Mother-to-child transmission can be prevented by giving antiviral drugs to HIV-positive mothers during their pregnancy and to their newborn children. But, although most mothers in developed countries have access to this intervention, fewer than half of HIV-positive mothers in low- and middle-income countries receive this treatment and, every year, nearly half a million children become infected with HIV.
Why Was This Study Done?
It is generally thought that HIV infections in infants progress rapidly and that half of the children who acquire HIV from their mothers will die before their second birthday if not treated with antiretroviral drugs. However, as the AIDS epidemic matures, more children are surviving to adolescence with untreated, vertically acquired HIV infection in sub-Saharan Africa, the region where most children with HIV/AIDS live. Little is known about the burden of HIV infection and its contribution to illness and death in adolescents in sub-Saharan Africa but this information is needed to help health care providers prepare for this new aspect of the AIDS epidemic. In this study, the researchers examine the causes of acute hospital admissions (admissions for conditions with a sudden onset and usually a short course) among adolescents in Zimbabwe, a country where the HIV epidemic started early and where one in seven adults is HIV-positive and more than 17,000 children are infected with HIV every year, mainly through vertical transmission.
What Did the Researchers Do and Find?
The researchers recruited 301 10–18-year olds who were admitted to each of the two public hospitals in Harare (Zimbabwe) for acute illnesses between September 2007 and April 2008. Each patient completed a questionnaire about themselves and their health and underwent standard investigations, including HIV testing. Nearly half the participants were HIV positive; about a quarter of these HIV-positive individuals only found out about their status during the study. HIV-positive participants were more likely to be stunted, to have pubertal delay, and to be maternal orphans or have an HIV-infected mother than HIV-negative participants. 69% of HIV-positive participants were admitted to hospital because of infections, often tuberculosis or pneumonia whereas only 19% of the HIV-negative participants were admitted for infections. More than a quarter of all the participants had underlying heart, lung, or other chronic conditions. Finally, 22% of the HIV-positive participants died while in hospital compared to only 7% of the HIV-negative participants. Factors that increased the risk of death among all the participants were advanced HIV infection, pubertal immaturity, and chronic conditions.
What Do These Findings Mean?
These findings indicate that HIV infection is the commonest cause of acute adolescent admission to hospital in Harare (and probably elsewhere in Zimbabwe). Most of these admissions are due to opportunistic infections similar to those seen in HIV-positive adults and to long-term complications of having HIV/AIDS as an infant such as delayed puberty. Other findings indicate that most of the HIV-positive adolescents who participated in this study were infected via vertical transmission, which supports the idea that long-term survival after vertical infection is possible. Because the AIDS epidemic started early in Zimbabwe, there is likely to be a lag before adolescent survivors of vertical HIV transmission become common elsewhere. Nevertheless, all African countries and other places where HIV infection in adults is common need to recognize that the burden of HIV in their acutely unwell adolescents is likely to increase over the next few years. To deal with this emerging aspect of the AIDS epidemic, measures must be introduced to ensure early diagnosis of HIV in this previously neglected age group so that treatment can be started before HIV-positive adolescents become critically ill.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000178.
This study is further discussed in a PLoS Medicine Perspective by Glenda Gray
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS, including a list of articles and other sources of information about the primary care of adolescents with HIV
Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on the HIV and AIDS in Zimbabwe, and on children, HIV, and AIDS (in English and Spanish)
UNICEF also has information about children and HIV and AIDS (in several languages)
Related Articles
Molecular Evidence of Interhuman Transmission of Pneumocystis Pneumonia among Renal Transplant Recipients Hospitalized with HIV-Infected Patients
Rabodonirina, Meja
Vanhems, Philippe
Couray-Targe, Sandrine
Gillibert, René-Pierre
Ganne, Christell
Nizard, Nathalie
Colin, Cyrille
Fabry, Jacques
Touraine, Jean-Louis
van Melle, Guy
Nahimana, Aimable
Francioli, Patrick
Hauser, Philippe M.
Emerging Infectious Diseases
Molecular evidence indicates that P. jirovecii may be nosocomially transmitted to severely immunosuppressed patients.
Ten Pneumocystis jirovecii pneumonia (PCP) cases were diagnosed in renal transplant recipients (RTRs) during a 3-year period. Nosocomial transmission from HIV-positive patients with PCP was suspected because these patients shared the same hospital building, were not isolated, and were receiving suboptimal anti-PCP prophylaxis or none. P. jirovecii organisms were typed with the multitarget polymerase chain reaction–single-strand conformation polymorphism method. Among the 45 patients with PCP hospitalized during the 3-year period, 8 RTRs and 6 HIV-infected patients may have encountered at least 1 patient with active PCP within the 3 months before the diagnosis of their own PCP episode. In six instances (five RTRs, one HIV-infected patient), the patients harbored the same P. jirovecii molecular type as that found in the encountered PCP patients. The data suggest that part of the PCP cases observed in this building, particularly those observed in RTRs, were related to nosocomial interhuman transmission.
Epidemiology; Pneumocystis carinii; Pneumocystis jirovecii; interhuman transmission; cluster analysis; sulfa drug resistance; dihydropteroate synthase; single-strand conformation polymorphism; PCP; research
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Adjunctive steroid in HIV-negative patients with severe Pneumocystis pneumonia
Lemiale, Virginie
Debrumetz, Alexandre
Delannoy, Alexandra
Alberti, Corinne
Azoulay, Elie
Respiratory Research
High-dose steroid therapy has been proven effective in AIDS-related Pneumocystis pneumonia (PCP) but not in non-AIDS-related cases. We evaluated the effects on survival of steroids in HIV-negative patients with PCP.
Retrospective study patients admitted to the ICU with hypoxemic PCP. We compared patients receiving HDS (≥1 mg/Kg/day prednisone equivalent), low-dose steroids (LDS group, <1 mg/Kg/day prednisone equivalent), and no steroids (NS group). Variables independently associated with ICU mortality were identified.
139 HIV-negative patients with PCP were included. Median age was 48 [40–60] years. The main underlying conditions were hematological malignancies (n=55, 39.6%), cancer (n=11, 7.9%), and solid organ transplantation (n=73, 52.2%). ICU mortality was 26% (36 deaths). The HDS group had 72 (51.8%) patients, the LDS group 35 (25%) patients, and the NS group 32 (23%) patients. Independent predictors of ICU mortality were SAPS II at ICU admission (odds ratio [OR], 1.04/point; [95%CI], 1.01-1.08, P=0.01), non-hematological disease (OR, 4.06; [95%CI], 1.19-13.09, P=0.03), vasopressor use (OR, 20.31; 95%CI, 6.45-63.9, P<0.001), and HDS (OR, 9.33; 95%CI, 1.97-44.3, P=0.02). HDS was not associated with the rate of ICU-acquired infections.
HDS were associated with increased mortality in HIV-negative patients with PCP via a mechanism independent from an increased risk of infection.
Pneumocystis jiroveci infection; Immunocompromised host; Mortality
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Outcomes of Moderate-to-Severe Pneumocystis Pneumonia Treated with Adjunctive Steroid in Non-HIV-Infected Patients▿†
Moon, Song Mi
Kim, Tark
Sung, Heungsup
Kim, Mi-Na
Kim, Sung-Han
Choi, Sang-Ho
Jeong, Jin-Yong
Woo, Jun Hee
Kim, Yang Soo
Lee, Sang-Oh
Antimicrobial Agents and Chemotherapy
While it is well-known that adjunctive corticosteroid use improves the outcome of moderate-to-severe Pneumocystis jirovecii pneumonia (PcP) in patients with human immunodeficiency virus (HIV), there are limited data on its efficacy in non-HIV-infected patients with PcP. Patients undergoing fiber-optic bronchoscopy with bronchoalveolar lavage for suspected PcP from January 2007 through December 2010 were reviewed retrospectively. We compared demographics, clinical characteristics, and outcomes in 88 non-HIV-infected patients with moderate-to-severe PcP with (n = 59) and without (n = 29) adjunctive corticosteroid use. Outcomes of PcP were assessed by respiratory failure and 30-day and 90-day all-cause mortality. Survival curves were analyzed by the Kaplan-Meier method and estimated by the log rank test. All-cause mortality of moderate-to-severe PcP at 90 days was lower in the solid-organ transplant recipients than in all other patients (6/26 [23%] versus 34/62 [55%], respectively; P = 0.006), and mortality at 30 days was lower in patients with hematologic malignancies than in all other patients (4/26 [15%] versus 24/62 [39%], respectively; P = 0.03). The outcomes of PcP were not significantly different in moderate-to-severe PcP patients with and without adjunctive corticosteroid use, regardless of recent corticosteroid use. Survival analysis of PcP patients with and without corticosteroid use by the Kaplan-Meier method also did not reveal any difference (log rank test; P = 0.81). There again was no difference within the subgroup of PcP patients with solid-organ transplants. Adjunctive corticosteroid use may not improve the outcome of moderate-to-severe PcP in non-HIV-infected patients.
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Clinic HIV-Focused Features and Prevention of Pneumocystis Carinii Pneumonia
Turner, Barbara J
Markson, Leona
Cocroft, James
Cosler, Leon
Hauck, Walter W
Journal of General Internal Medicine
To examine the association of clinic HIV-focused features and advanced HIV care experience with Pneumocystis carinii pneumonia (PCP) prophylaxis and development of PCP as the initial AIDS diagnosis.
Nonconcurrent prospective study.
New York State Medicaid Program.
Medicaid enrollees diagnosed with AIDS in 1990–1992.
We collected patient clinical and health care data from Medicaid files, conducted telephone interviews of directors of 125 clinics serving as the usual source of care for study patients, and measured AIDS experience as the cumulative number of AIDS patients treated by the study clinics since 1986. Pneumocystis carinii pneumonia prophylaxis in the 6 months before AIDS diagnosis and PCP at AIDS diagnosis were the main outcome measures. Bivariate and multivariate analyses adjusted for clustering of patients within clinics. Of 1,876 HIV-infected persons, 44% had PCP prophylaxis and 38% had primary PCP. Persons on prophylaxis had 20% lower adjusted odds of developing PCP (95% confidence interval [CI] 0.64, 0.99). The adjusted odds of receiving prophylaxis rose monotonically with the number of HIV-focused features offered by the clinic, with threefold higher odds (95% CI 1.6, 5.7) for six versus two or fewer such features. Patients in clinics with three HIV-focused features had 36% lower adjusted odds of PCP than those in clinics with one or none. Neither clinic experience nor specialty had a significant association with prophylaxis or PCP.
PCP prevention in our study cohort appears to be more successful in clinics offering an array of HIV-focused features.
Pneumocystis carinii pneumonia (PCP); AIDS; clinical competence; ambulatory care; case management
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Blood (1→3)-β-D-Glucan as a Diagnostic Test for HIV-Related Pneumocystis jirovecii Pneumonia
Sax, Paul E.
Komarow, Lauren
Finkelman, Malcolm A.
Grant, Philip M.
Andersen, Janet
Scully, Eileen
Powderly, William G.
Zolopa, Andrew R.
Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America
In a large group of HIV-infected clinical trial participants with diverse opportunistic infections, blood beta-glucan was a more sensitive noninvasive test for PCP than serum LDH; sensitivity was also higher than that frequently reported for induced sputum examinations.
(See the editorial commentary by Morris and Masur, on pages 203–204.)
Background. Improved noninvasive diagnostic tests for Pneumocystis jirovecii pneumonia (PCP) are needed. We evaluated the test characteristics of plasma (1→3)-β-D-glucan (β-glucan) for HIV-related PCP among a large group of patients presenting with diverse opportunistic infections (OIs).
Methods. The study population included all 282 participants in AIDS Clinical Trials Group A5164, a study of early versus deferred antiretroviral therapy in conjunction with initial therapy of acute OIs. Baseline plasma samples were assayed for β-glucan, with standard assay reference values defining ≥80 pg/mL as positive. Before this analysis, diagnosis of PCP was independently adjudicated by 2 study investigators after reviewing reports from study sites.
Results. A total of 252 persons had a β-glucan result that could be analyzed, 173 (69%) of whom had received a diagnosis of PCP. Median β-glucan with PCP was 408 pg/mL (interquartile range [IQR], 209–500 pg/mL), compared with 37 pg/mL (IQR, 31–235 pg/mL) without PCP (P < .001). The sensitivity of β-glucan dichotomized at 80 pg/mL for the diagnosis of PCP was 92% (95% confidence interval [CI], 87%–96%), and the specificity was 65% (95% CI, 53%–75%); positive and negative predictive values were 85% (95% CI, 79%–90%) and 80% (95% CI, 68%–89%) respectively, based on the study prevalence of 69% of patients with PCP. Rates of abnormal lactate dehyrogenase levels did not differ significantly between those with and without PCP.
Conclusions. Blood (1→3)-β-D-glucan is strongly correlated with HIV-related PCP. In some clinical centers, this may be a more sensitive test than the induced sputum examination and could reduce the need for both bronchoscopy and empirical therapy of PCP.
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AIDS in Africans living in London.
O'Farrell, N
Lau, R
Yoganathan, K
Bradbeer, C S
Griffin, G E
Pozniak, A L
Genitourinary Medicine
OBJECTIVES--To investigate the presentation of HIV infection and AIDS amongst Africans diagnosed with AIDS living in London. METHODS--Identification of all AIDS cases of African origin attending four HIV specialist centres in South London--Guy's, King's, St George's and St Thomas' Hospitals--up to March 1994, by retrospective review of case notes of all HIV positive patients. RESULTS--Of 86 patients (53 women, 33 men) studied, 59 (69%) were from Uganda. The most frequent AIDS-defining diagnoses were: Pneumocystis carinii pneumonia (PCP) 21%, tuberculosis (TB) 20% (extrapulmonary TB 14%, pulmonary TB 6%), cerebral toxoplasmosis 14%, oesophageal candida 13%, cryptococcal meningitis 11%, wasting 6%, herpes simplex infection > 1 month 5%, Kaposi's sarcoma 5%, other 6%. Cytomegalovirus retinitis was diagnosed in one case. Late presentation was common; 70% were diagnosed HIV positive when admitted to hospital. The diagnosis of AIDS was coincident with a first positive HIV test result in 61%. The mean CD4 counts at both HIV and AIDS diagnoses were similar in both men and women: 87 x 10(6)/l and 74 x 10(6)/l in men and 99 x 10(6)/l and 93 x 10(6)/l in women respectively. Overall, TB 21 (24%) (extrapulmonary TB 12, pulmonary TB 9) was either the AIDS-defining diagnosis or was detected within three months of this event. Sixty-two per cent of TB cases were diagnosed within twelve months of entry to the UK compared to 34% of all other AIDS cases. The prevalence of STD was very low; genital herpes was the commonest STD: 17% of the women, 9% men; 28% of the men and 11% of the women tested had a positive TPHA test. In cases known to be HIV-positive prior to an AIDS diagnosis, 41% took prophylaxis for PCP and 45% had taken zidovudine (ZDV). Forty two of the study participants had 89 children: 59 of these children had mothers in the study. Overall, 37 (42%) of the children had lost at least one parent at the time of data assessment. CONCLUSIONS--PCP and TB were the most common initial AIDS-defining diagnoses. The majority of TB cases were diagnosed within 12 months of entry to the UK. An AIDS-defining diagnosis was the first manifestation of HIV-related illness in the majority of patients. Because of late presentation to medical services, access to treatments for HIV infection and prophylaxis against opportunistic infections was limited. Extending the role of clinics and staff into the community might facilitate both earlier presentation and access to services. Future provision of local services will need to be sensitive to the requirements of individuals from different cultures and backgrounds.
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- Sleep duration, restfulness, and screens in the sleep environmentJennifer Falbe
Division of Community Health and Human Development, School of Public Health, University of California Berkeley, Berkeley, California
Pediatrics 135:e367-75. 2015..Therefore, we examined associations of different screens in sleep environments with sleep duration and perceived insufficient rest or sleep...
- Adiposity and different types of screen timeJennifer Falbe
Division of Community Health and Human Development, University of California, Berkeley School of Public Health, 50 University Hall 7360, Berkeley, CA 94720
Pediatrics 132:e1497-505. 2013..Our objective was to assess independent relations of television, electronic games (video/computer), and digital versatile disc (DVD)/videos and total screen time with change in adolescent BMI...


text:
On the fence about getting me and the kids flu shots? Any thoughts would be helpful!
Flu Shot - Yes or No?
Oh the the first 2 years i allowed the dr to talk me into giving ODS the flu shot he had the flu 3, yes 3 confirmed times. He hasnt had the shot the last 2 years, nor will he get one this year, and he hasnt had the flu since. Also those 2 years, i was cuddling with him during the entire illness, breathing breathed on etc and i didnt even get sick. i have never had the flu shot, ever and havent had the flu but twice and the last time i was 7 or 8.
yes...both my kids got it and DH and i have been getting them the past 3 years to help our kids not get it. the kids got theirs so far but we have not received ours yet.
i work in health care and i guess in the next 2 years, it will be mandatory for me to receive it.
~ Kerry
mommy to M 8/09 & D 11/11
I know it causes serious controversy every year, but yes I take the flu shot every year. My kids take the flu mist. I am a nurse and my employer requires the flu shot for employees.
Join us on Working Moms!
I'm undecided. The PA I saw for my daughter recommended it for her (18 mo.) and said there's a shot that isn't live that they use for littles and for pregnant women...which I am, which is why I'm unsure for myself. I've heard yes and no for pregnancy, so I guess I'm just going to talk to my own doctor and go from there...
Go green - pee in the shower.
No way. My kids have egg allergies and never get sick so it's never happening.
Say NO to snow!
I have to get it, or I'll get fired. I'd get one even if it wasn't a requirement for my job. My kids get them too.
I bet she would like it if she was fast.
My job at the hospital required me to get one. I get one every year. Now that I work in an office, I still get one. I was hospitalized from influenza in college 2 years in a row. My ds has weakened lungs and so we all get it. He has never had adverse side effects and neither have the rest of us. My dh got it and was one of the only teachers not to come down with influenza 2 winters ago.
When your child almost dies from RSV virus and each year is weezing his way through the cold weather, the influenza shot is a must. I don't give a flying fig what other people do with their kids or families though. Luckily, I don't have to waste my energy on that.
"You ought to be thankful, a whole heaping lot, for the places and people you're lucky you're not." - Dr. Suess
She was a brave woman who faced the Moby Dick of poops, and lost. - Ashley's Closet


text: hey guys i just wanted to confirm something; so, for systems of continuous energy states (or small separations of discrete energy states), we can plot a graph like this and call the fermi energy the middle point where Probability=1/2. like this where, if T=0K, the transition from occupancy to no occupancy is sharp. as T increases the fermi level doesn't change, as the constituent particles say... the electrons, occupy higher energy states. but this is for a smooth ("smooth"...) distribution of energy states. but for the case of a semiconductor, where the existent energy states are not so smooth going from the valence band to the conduction band, how do i know where the fermi energy level is? the graph in this image/scenario i've plotted for a non-zero temperature case (as apparent by the nonzero occupancy in the C-band region). Take a look at the red region; i'm almost sure that this region should have zero occupancy of electrons BUT, i'm reading an introductory paper on semiconductors and they are referring to the fermi level being right in the middle between the V-band and C-band for the case where there are no excess carriers (no excess electrons and no excess holes). I don't understand how the fermi level can be in the middle when the fermi level is defined as (i thought..) the energy at which the probability of occupancy is 1/2. but the occupancy probability in the band gap is zero.. so how can it be there? thanks


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Published on Jan 08, 2013
This lecture was given in September, 2009 as part of the California native plant gardening series 'Out of the Wilds and Into Your Garden'
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