Laura Kogelman

Acute respiratory distress syndrome complicating Plasmodium vivax malaria.

Malaria is one of the most common infectious diseases in the world, and severe respiratory complications have been described mainly in association with Plasmodium falciparum. We describe a case of acute respiratory distress syndrome complicating infection with P. vivax in the setting of relatively low parasitemia in a 47-yr-old woman after a brief trip to Papua New Guinea. A review of the literature shows that pulmonary complications of P. vivax are rare but occur more frequently than generally acknowledged. Pathogenic mechanisms of these complications are discussed.

International travel by persons with medical comorbidities: understanding risks and providing advice.

OBJECTIVE To describe the medical conditions, travel plans, counseling, and medications prescribed for high-risk international travelers. PATIENTS AND METHODS This cross-sectional study was conducted from March 1, 2008, through July 31, 2010, in 5 clinics in the greater Boston area. We assessed all travelers seen for pretravel care and compared demographic characteristics, travel plans, pretravel counseling, and interventions for healthy and high-risk travelers (as defined by medical history or pregnancy). RESULTS Of 15,440 travelers, 2769 (17.9%) were high-risk; 644 of 2769 (23.3%) were immunocompromised travelers, 2056 (74.3%) had medical comorbidities, and 69 (2.5%) were pregnant women. The median age of high-risk travelers was 47 years compared with 32 years for healthy travelers (P=.0001). High-risk travelers visited the clinic a median of 25 days (range, 10-44 days) before departure. Overall, 2562 (93.9%) of high-risk travelers visited countries with medium or high risk of typhoid fever, 2340 (85.7%) visited malaria-risk countries, and 624 (22.8%) visited yellow fever-endemic countries. Of travelers to yellow fever-endemic countries, 8 of 23 (34.8%) pregnant women and 64 of 144 (44.4%) immunocompromised travelers received yellow fever vaccine. Of eligible high-risk travelers, 11 of 76 (14.5%) received a pneumococcal vaccine, 213 of 640 (33.3%) influenza vaccine, and 956 of 2681 (35.7%) either tetanus-diphtheria or tetanus-diphtheria-pertussis vaccine. CONCLUSION High-risk travelers made up nearly 20% of patients in these travel clinics, and they mostly traveled to destinations with malaria and typhoid risk. For health care professionals caring for travelers with underlying medical problems, providing appropriate travel counseling and making vaccine decisions, such as for yellow fever, are complex. Travelers with complicated medical histories may warrant evaluation by an experienced travel medicine specialist.

Tigecycline-induced acute pancreatitis: case report and literature review

Tigecycline is a broad-spectrum antimicrobial agent structurally related to minocycline. Pancreatitis has been associated with the tetracycline class of antibiotics and concerns about tigecycline-induced acute pancreatitis have recently been raised. We describe a 69-year-old female who received tigecycline for treatment of a complicated skin and skin-structure infection. Following 7 days of tigecycline she developed severe abdominal pain and elevated pancreatic enzymes suggesting acute pancreatitis. According to the Naranjo adverse drug reaction probability scale, tigecycline was the probable cause of her acute pancreatitis. Clinicians should be aware of this potential adverse effect of tigecycline. We recommend that clinicians monitor patients for signs and symptoms of pancreatitis, including abdominal pain, during treatment with tigecycline.

Knowledge, attitudes, and practices of US practitioners who provide pre-travel advice.

BACKGROUND As international travel increases, many health care professionals are being asked to provide pre-travel advice. We designed an anonymous web-based survey to assess the extent to which primary care providers (PCPs) provide travel medicine advice and how their understanding and delivery of itinerary-specific advice and management compare with that of travel medicine specialists. METHODS We surveyed randomly selected US PCPs registered in the Pri-Med Institute (now pmiCME) database and US travel medicine specialists from the International Society of Travel Medicine (ISTM), American Society of Tropical Medicine and Hygiene (ASTMH), and Centers for Disease Control and Prevention (CDC) yellow fever (YF) vaccine provider mailing lists. SAS software (SAS Institute, Cary, NC, USA) was used for all analyses. RESULTS Of 14,932 e-mails sent to valid e-mail addresses, 902 yielded complete or partially completed surveys (6.0% response rate). Eighty percent of respondents personally provided pre-travel advice (95% of travel medicine specialists versus 73% of PCPs). About two thirds of PCPs (68%) providing pre-travel consultations saw <50 travelers per year whereas 30% of travel medicine specialists saw <50 travelers per year. More travel medicine specialists (59%) than PCPs (18%) saw >500 travelers per year. Familiarity with travel-specific vaccines (YF, Japanese encephalitis) and provision of written educational materials increased as volume of travelers increased. Familiarity with antimalarial side effects and malaria resistance patterns, and knowledge scores based on brief pre-travel scenarios were higher in travel medicine specialists, ASTMH or ISTM certificate holders, and respondents who saw more pre-travel patients. CONCLUSIONS Many PCP survey participants provided pre-travel advice, but most saw few travelers. Volume of travelers and holding an ASTMH or ISTM certificate had the greatest influence on knowledge of travel medicine and provision of appropriate advice and recommendations. Creating easily accessible travel medicine education programs for US providers from a wide range of disciplines is needed to improve the management of travelers.

Progressive neurodegeneration after intracerebroventricular kainic acid administration in rats: Implications for schizophrenia?

BACKGROUND Intracerebroventricular (ICV) administration of kainic acid to rats produces limbic-cortical neuronal damage that has been compared to the neuropathology of schizophrenia. METHODS Groups of adult rats were administered ICV kainic acid and then assessed for neuronal loss and the expression of proteins relevant to mechanisms of neuronal damage after one and fourteen days. Neuronal loss was assessed by two-dimensional cell counting and protein expression was assessed by immunohistochemistry. RESULTS ICV kainic acid administration was associated with both immediate (day 1) and delayed (day 14) neuronal loss in the dorsal hippocampus. The immediate injury was largely limited to the CA3 hippocampal subfield, while the delayed injury included the CA1 subfield. Multiple mechanisms of cell death appeared to be involved in the delayed neuronal loss, as evidenced by changes in the expression of glutamate receptor subunits, heat shock protein and jun protein. CONCLUSIONS ICV kainic acid administration to adult rats produces progressive damage to limbic-cortical neurons, involving both fast and slow mechanisms of cell death. Given the evidence for clinical deterioration, cognitive deficits and hippocampal neuropathy in some cases of schizophrenia, this animal model may be relevant for hypotheses regarding mechanisms of neurodegeneration in that disorder.

Health challenges of young travelers visiting friends and relatives compared with those traveling for other purposes.

Background: The study objective was to assess differences in demographics and travel health challenges between youths ⩽18 years old traveling internationally to visit friends and relatives (VFRs) compared with those traveling for other purposes (non-VFR). Methods: The Boston Area Travel Medicine Network consists of 5 clinics collecting anonymous data from international pretravel consultations. Data on all travelers ⩽18 years of age seen between January 2008 and July 2010 were used. VFRs were compared with non-VFRs on demographics, primary language, trip characteristics, travel vaccinations administered, malaria prophylaxis and antidiarrheal medications prescribed. Results: Thirty-five percent (610/1731) listed VFR as their purpose of travel. Almost half of VFRs were <5 (46%) years old compared with <5% of non-VFRs. Thirty percent of US-born VFRs with foreign-born parents were ⩽2 years compared with 4% of foreign-born VFR children and 3% of US-born VFRs with US-born parents. More VFRs than non-VFRs planned travel to countries that were yellow fever holoendemic, had malaria risk and were high-risk for typhoid (44% versus 20%, 39% versus 12%, 25% versus 15%, P < 0.01). VFRs were less likely than non-VFRs to be prescribed atovaquone-proguanil (adjusted prevalence ratio = 0.57, confidence interval = 0.44–0.72) and to have had an antidiarrheal medication prescribed (adjusted prevalence ratio = 0.68, confidence interval = 0.60–0.75). Conclusions: To reduce travel-related morbidity, healthcare providers should be prepared to give travel advice to parents of VFR infants and children, particularly those US-born VFRs with foreign-born parents, regarding antimalarial and antidiarrheal medications and preventing yellow fever, malaria and typhoid.

Treatment acceptance and adherence in HIV disease: patient identity and the perceived impact of physician-patient communication.

Studies have found that physician–patient relationships and communication quality are related to medication adherence and outcomes in HIV care. Few qualitative studies exist of how people living with HIV experience clinical communication about their self-care behavior. Eight focus groups with people living with HIV in two US cities were conducted. Participants responded to a detailed discussion guide and to reenactments of actual physician–patient dialogue about antiretroviral adherence. The 82 participants were diverse in age, sex, and ethnicity. Most had been living with HIV for many years and had stable relationships with providers. They appreciated providers who knew and cared about their personal lives, who were clear and direct about instructions, and who were accessible. Most had struggled to overcome addiction, emotional turmoil, and/or denial before gaining control over their lives and becoming adherent to medications. They made little or no causal attribution for their transformation to any outside agency, including their providers. They generally saw medication adherence as a function of autonomous motivation. Successful coping with HIV with its prevalent behavioral comorbidities, stigma, and other challenges requires a transformation of identity and internalization of motivation to maintain health. Effective methods for clinicians to support such development are needed.

Prevalence of Dengue Virus Infection in US Travelers Who Have Lived in or Traveled to Dengue-Endemic Countries

BACKGROUND Dengue virus (DENV) infections may occur in travelers. OBJECTIVES To determine prevalence of anti-DENV IgG antibody in travelers who lived in or visited dengue-endemic countries and to describe risk factors and characteristics associated with infection and subsequent anti-DENV IgG antibody presence. METHODS Participants were enrolled from travel clinics of the Boston Area Travel Medicine Network from August 2008 through June 2009. Demographic information, trip duration, travel history, and a blood sample were collected. Serum samples were tested for anti-DENV IgG antibody by indirect IgG enzyme-linked immunosorbent assay (ELISA), and antibody-mediated virus neutralization by plaque reduction neutralization test (PRNT) for anti-DENV IgG antibody-positive and selected negative samples. Participants were stratified into group 1: born in dengue-endemic countries; group 2: born in nonendemic countries but lived continuously for ≥1 year in a dengue-endemic country; group 3: born in nonendemic countries and traveled to a dengue-endemic country for ≥2 weeks but <1 year. RESULTS Six hundred travelers were enrolled. Anti-DENV IgG antibody was identified in 113 (19%) when tested by ELISA (51% in group 1, 40% in group 2, and 6.9% in group 3) and in 71 (12%) by PRNT (42% primary monotypic and 58% heterotypic reactive responses). Sensitivity and specificity of the ELISA based on PRNT results were 85% to 100% and 79% to 94%, assuming up to 15% misclassification of ELISA negative results. Presence of anti-DENV IgG antibody by ELISA was associated with years lived in dengue-endemic countries and birthplace in the Caribbean for group 1, receipt of Japanese encephalitis vaccine in group 3, and self-reported history of dengue in all three groups. CONCLUSIONS Nineteen percent of participants who were born, lived in, or traveled to dengue-endemic countries had anti-DENV IgG antibody by ELISA; 12% had antibodies by PRNT, 85% of whom had no history of dengue. Presence of DENV antibodies was associated with years lived in dengue-endemic countries and self-reported history of dengue.

Health Literacy in HIV Treatment: Accurate Understanding of Key Biological Treatment Principles is Not Required for Good ART Adherence

Findings on the relationship between health literacy and outcomes in HIV have been inconsistent. Health literacy has previously been operationalized as general functional literacy, but has not included content knowledge about HIV disease and treatment. Semi-structured interviews with people living with HIV in 2 U.S. cities, including questions about the etiology, pathophysiology and treatment of HIV. We compared responses to biomedical conceptions. The 32 respondents were demographically diverse. Although most understood that HIV degrades the immune system, none could explain the nature of a virus, or the mechanism of antiretroviral (ARV) drug action. Fewer than half accurately reported that it is desirable to have a high CD4+ cell count and low viral load. A minority understood the concept of drug resistance. While most believed that strict adherence to ARV regimens was important to maintain health, three believed that periodic treatment interruption was beneficial, and three believed they should not take ARVs when they used alcohol or illicit drugs. Respondents generally had very limited, and often inaccurate biomedical understanding of HIV disease. Most reported good regimen adherence but did not have any mechanistic rationale for it. The failure to find a consistent relationship between health literacy and ARV adherence may be largely because most people simply follow their doctors’ instructions, without the need for deep understanding.

Hepatitis B screening in US travelers seen at the Boston area travel medicine network.

BACKGROUND Persons born in countries with hepatitis B surface antigen (HBsAg) prevalence ≥2% have increased risk for unrecognized hepatitis B virus (HBV) infection. Testing at pre-travel consultations is a strategy to identify previously undiagnosed HBV infections. Using records of travelers seen at the Boston Area Travel Medicine Network (BATMN) sites, we assessed how these travel clinics currently assess HBV status, describe test results, and describe characteristics of those tested and immunized for HBV. METHODS Demographic data and trip information were collected for all travelers seen at the BATMN sites from June 2008 through July 2010. Proportions of those tested for HBV were determined, and differences between those tested and not tested were analyzed. RESULTS Among 13,732 travelers enrolled during the study period, 2,134 (16%) were born in HBV-risk countries (HBsAg prevalence ≥2%); 532/2134 (25%) had previous HBV test results and 230 (11%) had tests performed at the travel clinic visit. Past results showed that 33/453 (7.3%) were HBV-infected (HBsAg+), 252/481 (52.4%) were immune (anti-HBs+, HBsAg-), 164/303 (54.1%) were susceptible (anti-HBs-, HBsAg-, anti-HBc-), and 38/314 (12.1%) had possible HBV exposure (anti-HBc+, HBsAg-, anti-HBs-). Among 230 travelers tested during the travel clinic visit, 7/213 (3.3%) were HBV-infected, 95/218 (43.6%) were immune, 106/179 (59.2%) were susceptible, and 10/182 (5.5%) had possible HBV exposure. CONCLUSION The travel clinic offers an opportunity to capture, identify, and educate infected persons unaware of their infection, educate those with known results, and initiate preventive action (eg, vaccination) for those still susceptible.