Babesia microti variant with multiple resistance mutations detected in an immunocompromised patient receiving atovaquone prophylaxis

We report Babesia microti genomic sequences with multiple mutations in the atovaquone-target region of cytochrome b, including a newly identified Y272S mutation, plus one mutation of undetermined significance in the azithromycin-associated ribosomal protein L4. The parasite was sequenced from an immunocompromised patient on prophylactic atovaquone for Pneumocystis pneumonia prior to diagnosis of babesiosis.

Management of immunotherapy colitis: Special considerations in the COVID-19 era

The evaluation and management of patients with cancer with suspected immune checkpoint inhibitor (ICI) colitis have distinct challenges within the setting of the coronavirus disease 2019 (COVID‐19) pandemic. The approach to the treatment of patients with ICI colitis requires consideration of the risks and benefits of individual immunosuppressive medications and varies based on the presence of a concurrent COVID‐19 infection.

Serial Procalcitonin as a Predictor of Bacteremia and Need for Intensive Care Unit Care in Adults With Pneumonia, Including Those With Highest Severity: A Prospective Cohort Study

Background

Procalcitonin (PCT) is a prohormone that rises in bacterial pneumonia and has promise in reducing antibiotic use. Despite these attributes, there are inconclusive data on its use for clinical prognostication. We hypothesize that serial PCT measurements can predict mortality, intensive care unit (ICU) admission, and bacteremia.

Methods

A prospective cohort study of inpatients diagnosed with pneumonia was performed at a large tertiary care center in Boston, Massachusetts. Procalcitonin was measured on days 1 through 4. The primary endpoint was a composite adverse outcome defined as all-cause mortality, ICU admission, and bacteremia. Regression models were calculated with area under the receiver operating characteristic curve (AUC) as a measure of discrimination.

Results

Of 505 patients, 317 patients had a final diagnosis of community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HCAP). Procalcitonin was significantly higher for CAP and HCAP patients meeting the composite primary endpoint, bacteremia, and ICU admission, but not mortality. Incorporation of serial PCT levels into a statistical model including the Pneumonia Severity Index (PSI) improved the prognostic performance of the PSI with respect to the primary composite endpoint (AUC from 0.61 to 0.66), bacteremia (AUC from 0.67 to 0.85), and need for ICU-level care (AUC from 0.58 to 0.64). For patients in the highest risk class PSI >130, PCT was capable of further risk stratification for prediction of adverse outcomes.

Conclusion

Serial PCT measurement in patients with pneumonia shows promise for predicting adverse clinical outcomes, including in those at highest mortality risk.

Emotional reactions in women attending a UK colposcopy clinic

STUDY OBJECTIVE

To assess the emotional responses of women attending a colposcopy clinic for investigation of an abnormal cervical smear, and to elicit the women's views on the screening service and colposcopy clinic.

DESIGN

Over 12 months all new attenders at a colposcopy clinic were invited to join the study. They were assessed psychiatrically four weeks before their first clinic appointment, and four weeks and 32 weeks after their first clinic appointment.

SETTING

Colposcopy clinic, John Radcliffe Hospital, Oxford.

PATIENTS

Of 114 women attending the colposcopy clinic for investigation of an abnormal cervical smear, 102 agreed to enter the study.

MEASUREMENTS

Psychiatric symptoms were assessed with a standardised psychiatric interview, the present state examination; and with four self rated mood scales:--the general health questionnaire, the Beck depression inventory, the Leeds depression scale, and the Leeds anxiety scale.

MAIN RESULTS

On all these measures, in the whole patient group, psychiatric morbidity was found to be transient and relatively minor. Thus ratings on the present state examination were not significantly higher than the rate found in a community sample of 520 women in Oxford, while on the four self rated mood scales, mean total scores were lower than the cut off value used to distinguished cases. Patient satisfaction with the colposcopy services was generally high but there was some dissatisfaction with delays.

CONCLUSIONS

After an abnormal cervical smear, further investigation by colposcopy is generally associated with low levels of anxiety and depression.

Energy intake and basal metabolic rate during maintenance chemotherapy

Energy intakes and basal metabolic rates were determined in 26 children receiving chemotherapy in remission from acute lymphoblastic leukaemia or solid tumours and 26 healthy controls matched for age and sex. Body weight and height on the two groups were comparable, although one patient was stunted (height for age) and three others wasted (weight for height). Energy intake in the patients at 7705 kJ/day (1842 kcal) and controls at 7773 kJ/day (1866 kcal)) and basal metabolic rate (BMR) in the patients at 4873 kJ/day (1172 kcal) and controls 4987 kJ/day (1196 kcal) for the two groups were not significantly different. Although the energy intake:BMR ratio for both groups was 1.59, the range of values for the patient group was large (0.96-2.73) and appeared to be greater than that observed in the control group (1.23-2.46). These results demonstrated that during this period of chemotherapy there was no evidence of raised energy expenditure at rest or reduced energy intake in the patient group. No indication of undernutrition in the patients as a group was evident, although some individuals might require further clinical nutritional assessment.

Evaluation of a brief psychological treatment for emotional disorders in primary care

A randomized trial in general practice compared: (i) a brief psychological treatment (problem-solving) given by a psychiatrist; (ii) any treatment of the GP's choice, whether psychological or pharmacological. The patients had recent onset emotional disorders of poor prognosis. Patients in the problem-solving group showed significantly greater reductions in symptoms. Problem-solving as given by a psychiatrist was feasible in primary care and acceptable to patients. Problem-solving is now being evaluated as given by general practitioners trained in the method.

Energy content of stools in normal healthy controls and patients with cystic fibrosis

Stool energy losses and the sources of energy within the stool were determined in 20 healthy controls and 20 patients with cystic fibrosis while on their habitual pancreatic enzyme replacement treatment. Stool energy losses were equivalent to 3.5% of gross energy intake in healthy children (range 1.3-5.8%). Despite a comparable gross energy intake, stool energy losses were three times greater in patients with cystic fibrosis than controls averaging 10.6% of gross energy intake (range 4.9-19.7%). Stool lipid could account for only 29% and 41% of the energy within the stool in controls and patients with cystic fibrosis respectively and was poorly related to stool energy. Approximately 30% of the energy within the stool could be attributable to colonic bacteria in both the healthy children and patients with cystic fibrosis. These results suggest that stool energy losses in healthy children are relatively modest but that even when patients with cystic fibrosis are symptomatically well controlled on pancreatic enzyme replacement, raised stool energy losses may continue to contribute towards an energy deficit sufficient to limit growth in cystic fibrosis. As the energy content per gram wet weight remains relatively constant (8 kJ/g), stool energy losses may be estimated from simple measurements of stool wet weight.

Treatment of short normal children with growth hormone--a cautionary tale?

41 short normal children were randomly allocated either to daily injections of growth hormone (rhGH) at 30 IU/m2 per week or to no treatment. 6 months of rhGH therapy produced up to 76% loss of fat mass and up to 25% increase in lean body mass (LBM). These changes were significantly different from those in the untreated group. LBM was the main determinant of resting energy expenditure (REE) expressed as kJ/24 h. REE expressed as kJ/kg LBM per 24 h correlated negatively with height, which was responsible for 66% of the variance in REE kJ/kg LBM per 24 h. Short children therefore expend more energy than tall children in fulfilling basic metabolic needs. After 6 months REE kJ/24 h increased significantly in treated children. However, treated children did not differ significantly from untreated children in REE kJ/kg LBM per 24 h. rhGH does not therefore seem to have a specific effect upon REE. The possibility that rhGH produces profound metabolic effects should limit its use in otherwise healthy children until the mechanism of action is more clearly elucidated.

Radio-Opaque Calcification of the Fallopian Tubes with Tubal Patency: (Section of Obstetrics and Gynæcology)

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