Thursday, June 11, 2009
Diagnosis and management of acute rhinosinusitis.
Postgrad Med. 2009 May
Hotel-Dieu de Montreal Hospital, 3840 St-Urbain Street, Montreal, Quebec, Canada. firstname.lastname@example.org
Acute rhinosinusitis (ARS) is a highly prevalent condition with substantial public health implications. The disease is associated with a high degree of disability, impairment of quality of life, and school and workplace absenteeism. Acute rhinosinusitis is most often precipitated by a viral upper respiratory infection or an episode of allergic rhinitis. Typical signs and symptoms include nasal congestion, purulent nasal discharge, headache, cough, and facial pain or tenderness. Diagnosis is usually based on patient history and physical examination. Specialist consultation is indicated for intractable or complicated disease, signified by signs or symptoms suggestive of orbital, intraosseous, or intracranial extension of sinus disease. Most cases of ARS in the ambulatory setting are viral. In the absence of severe or rapidly worsening symptoms, antibiotic prescription should be delayed until an appropriate surveillance period has elapsed. Symptomatic therapy is the most efficient approach for uncomplicated ARS. There is a paucity of data supporting use of commonly used symptomatic therapies, with the exception of intranasal corticosteroids, which have demonstrated rapid improvement of the symptoms of ARS and return to normal functioning when used as monotherapy or as an adjunct to antibiotics.
Bacterial Meningitis in HIV-1-Infected Patients in the Era of Highly Active Antiretroviral Therapy.
J Acquir Immune Defic Syndr. 2009 Jun
Domingo P, Suarez-Lozano I, Torres F, Pomar V, Ribera E, Galindo MJ, Cosin J, Garcia-Alcalde ML, Vidal F, Lopez-Aldeguer J, Roca B, Gonzalez J, Lozano F, Garrido M; on behalf of the VACH Cohort Study Group.
From the *Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; daggerHospital Infanta Elena, Huelva, Spain; double daggerLaboratori de Bioestadística i Epidemiologia (Universitat Autònoma de Barcelona), IDIBAPS (Hospital Clínic), Barcelona, Spain; section signHospital Vall d'Hebrón, Barcelona, Spain; parallelHospital Clinico, Valencia, Spain; paragraph signHospital Gregorio Marañón, Madrid, Spain; #Hospital de Cabueñes, Gijón, Spain; **Hospital Universitari de Tarragona Joan XXIII, IISPV, Universitat Rovira i Virgili, Tarragona; daggerdaggerHospital La Fe, Valencia, Spain; double daggerdouble daggerHospital General, Castellón, Spain; section sign section signHospital La Paz, Madrid, Spain; parallel parallelHospital de Valme, Sevilla, Spain; and paragraph sign paragraph signVACH Data Management Group, Huelva, Spain.
The burden that spontaneous bacterial meningitis (SBM) currently represents among HIV-1-infected patients is poorly known.
We prospectively evaluated 32 episodes of SBM in HIV-1-infected patients from the VACH (VIH-Aplicación de Control Hospitalario) Cohort and compared findings with those of 267 episodes in uninfected persons, matched by age and year of infection. A group of 13,187 HIV-1-infected patients from the VACH Cohort were used to identify predictors for acquiring SBM.
Between 1997 and 2006, we found 32 episodes of SBM among HIV-1-infected patients for an annual incidence rate of 62.0 cases per 100,000 population compared with 3.2 (3.0 to 3.4) per 100,000 population for uninfected patients (P <>/=200/mm count was the only predictor for developing SBM. Compared with uninfected, HIV-1-infected patients with SBM had a greater prevalence of primary extrameningeal infection, especially pneumonia (P = 0.02), bacteremia (P = 0.02), focal neurologic signs (P = 0.005), seizures (P = 0.06), a lower cerebrospinal fluid to blood glucose ratio (P = 0.02), and a lower prevalence of nuchal rigidity (P = 0.005). Streptococcus pneumoniae was the most frequent etiologic agent among HIV-1-infected patients. HIV-1-infected patients had neurologic complications more frequently (P = 0.02), a higher overall case fatality rate (P = 0.004), and greater incidence of neurologic sequelae (P = 0.001). '
Even in the highly active antiretroviral therapy era, the risk of developing SBM is 19 times higher among HIV-1-infected patients than among uninfected ones. It tends to present in severely immunosuppressed patients not previously vaccinated and off antiretroviral therapy, with a concomitant extrameningeal infection, bacteremia, and focal neurologic signs, and is caused by S. pneumoniae. SBM in HIV-1-infected patients carries a worse prognosis than in uninfected ones both in terms of lethality and sequelae.
PMID: 19512939 [PubMed - as supplied by publisher]