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Botulism is a rare but potentially lethal neuroparalytic illness that requires prompt recognition and treatment to reduce death rates and the possible spread of the disease. During the past 25 [...]

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Botulism is caused by a neurotoxin produced from the anaerobic, spore-forming bacterium Clostridium botulinum. Botulism in humans is usually caused by toxin types A, B, and E. Since 1973, a median of 24 cases of foodborne botulism, 3 cases of wound botulism, and 71 cases of infant botulism have been reported annually to the Centers for Disease Control and Prevention (CDC). New vehicles for transmission have emerged in recent decades, and wound botulism associated with black tar heroin has increased dramatically since 1994. Recently, the potential terrorist use of botulinum toxin has become an important concern. Botulism is characterized by symmetric, descending, flaccid paralysis of motor and autonomic nerves, usually beginning with the cranial nerves. Blurred vision, dysphagia, and dysarthria are common initial complaints. The diagnosis of botulism is based on compatible clinical findings; history of exposure to suspect foods; and supportive ancillary testing to rule out other causes of neurologic dysfunction that mimic botulism, such as stroke, the Guillain-Barre syndrome, and myasthenia gravis. Laboratory confirmation of suspected cases is performed at the CDC and some state laboratories. Treatment includes supportive care and trivalent equine antitoxin, which reduces mortality if administered early. The CDC releases botulism antitoxin through an emergency distribution system. Although rare, botulism outbreaks are a public health emergency that require rapid recognition to prevent additional cases and to effectively treat patients. Because clinicians are the first to treat patients in any type of botulism outbreak, they must know how to recognize, diagnose, and treat this rare but potentially lethal disease., Physicians must know the signs and symptoms of botulism to prevent potential outbreaks. Contaminated food can sometimes be a source of botulism, making this disease a public health emergency. It is caused by a toxin produced by the bacterium Clostridium botulinum. An average of 24 cases a year are reported to the CDC. The toxin produces paralysis that may start as blurred vision, difficulty speaking and swallowing. Tests must be performed to rule out other diseases that can mimic botulism. Treatment consists of antitoxin, which must be given as soon as possible.

Antiretroviral therapy (ART) during pregnancy is important for both maternal health and prevention of perinatal HIV-1 transmission; however adequate data on the safety and efficacy of different ART regimens that are likely to be used by pregnant women are scarce. In this trial we compared the safety and efficacy of three antiretroviral regimens started in pregnancy: dolutegravir, emtricitabine, and tenofovir alafenamide fumarate; dolutegravir, emtricitabine, and tenofovir disoproxil fumarate; and efavirenz, emtricitabine, and tenofovir disoproxil fumarate.

Among human immunodeficiency virus-positive women in Botswana on the recommended first-line antiretroviral therapy regimen, tenofovir-emtricitabine-efavirenz, initiated within the first or early second trimester, we found no increased risk of stillbirth, neonatal death, preterm/very preterm delivery, or the infant being born small or very small for gestational age. Treatment with tenofovir-emtricitabine-efavirenz <1 year before conception increased the risk of preterm delivery slightly over late-second-trimester treatment initiation (adjusted risk ratio, 1.33 [95% confidence interval, 1.04-1.70]).

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Low maternal 25(OH)D (vitamin D) values have been associated with higher mortality and impaired growth among HIV-exposed uninfected (HEU) infants of antiretroviral (ART)-naive women. These associations have not been studied among HEU infants of women receiving ART.

HAART for prevention of mother-to-child HIV transmission (MTCT) may impact long-term survival of women and children.

Background Pharmacokinetic data for lopinavir in late pregnancy and in breastfeeding are limited, and no data for abacavir in breast milk are available.Methods Women in the Mma Bana Study initiated HAART from 18 to 34 weeks of gestation. We determined trough plasma and whole breast milk concentrations of lopinavir (LPV), abacavir (ABC), nevirapine (NVP), lamivudine (3TC) and zidovudine (ZDV) among separate subsets of pregnant and breastfeeding women, and in plasma of exposed infants. Lopinavir was measured 1 month after starting HAART or 1 month postpartum, and other drugs were measured 1 month postpartum.Results Sampling occurred a median of 14 h (range 11–17) from last maternal drug ingestion. Although 50% higher median LPV levels were seen in postpartum than antepartum plasma (8.29 µg/ml versus 5.51 µg/ml; P=0.02), antepartum levels with standard LPV dosing were therapeutic for all women (>1.0 µg/ml). Very low LPV levels (<0.25 µg/ml) were detected in breast milk. Median ABC levels in breast milk were 85% of those in plasma (0.057 µg/ml versus 0.067 µg/ml). Breast milk concentrations of NVP and 3TC were 27% and 74% of plasma levels, respectively. At these trough maternal time points, only NVP was detectable in potentially inhibitory levels in breastfeeding infants, and most infants had non-detectable levels of LPV, ABC, ZDV and 3TC via maternal breast milk.Conclusions Standard LPV dosing achieved therapeutic levels in pregnancy and no appreciable concentrations in breast milk. ABC is detectable in breast milk at similar concentrations to plasma, but does not result in appreciable infant exposure.

Freud stated that external resistances to analysis, the patient's family relationships, frequently interfered with therapy more than the patient's own internal resistances. This is a central problem in the treatment of adolescents. The developments of structural theory and ego psychology included concepts and methods of defense analysis for the management of internal resistances. The external resistances may also be conceptualized from the structural and adaptive points of view. This then requires the development of methods of conjoint family interviewing for the management of external resistances to the treatment of adolescents. Such interviews should be part of the initial assessment of the disturbed adolescent. They establish a working alliance not only with the adolescent but with his family. For neurotic adolescents conjoint family interviews should be resumed when the external resistances become a serious interference with treatment. For borderline adolescents, where serious disturbances over separation-individuation are found in both adolescents and parents and profoundly interfere with adolescent development, concurrent psychoanalytic psychotherapy for the adolescent and analytic, group interpretive family treatment is indicated. Conceptualization and methods of family interviewing and family treatment concurrent with individual psychotherapy are discussed.

Multiple self-images held by 58 adolescents were studied using a specially developed Q-sort technique. A perceptual-cognitive process, psychological differentiation, was also followed. Results suggest that "realms" of self-image are selectively influenced by psychopathology, age, and sex. Patient-adolescents perceived greater discrepancy between all idealized views of themselves and their current self-images (lower correlations). But temporal self-images and peer self-images differentiated only between sex and age groups. A further sex difference finding was on the psychological differentiation measure. Findings are discussed in terms of psychoanalytic theories of adolescent development, particularly with reference to ego ideal. It is also argued that a psychoanalytic framework alone cannot account for the sex differences, which may be reflecting important cultural trends. Finally, the finding that patients have a lower overall integration of self-images is discussed in terms of "identity diffusion."

Using techniques derived from information theory, structural dimensions of adolescent self-images were studied. Within a sample of 58 adolescents, patients and normals, a variety of self-images were obtained using a specially designed Q-sort. The initial hypothesis predicted, on the basis of previous findings, that the idealized self-images would be more polarizedfor the patients. This hypothesis was only partiallyconfirmed. the self-idealization was significantly more polarized in the patient group. But the other two idealizations (those based on parental expectations) did not reflect a patient-normal difference. Rather, a significant three-way interaction of sex, age, and psychiatric status was found for these self-images, as well as for the current self-image. The consistent pattern in these three-way interactions was that late-adolescent boys polarized their self-images if they were in the normal group and had structurally complex (nonpolarized) self-images if they were in the patient group. The paper concludes by discussing the meaning of these findings. A framework for interpreting polarization is proposed and applied to the results. In addition, the notion of a “Self-Image Profile” is formulated and further elaborated. Finally, the relevance of these studies to other personality research and clinical observations is considered.

The World Health Organization recommends the use of highly active antiretroviral therapy (HAART) for prevention of mother-to-child transmission of human immunodeficiency virus during pregnancy and breast-feeding. Some observational studies have reported that use of protease inhibitor (PI)-based HAART is associated with preterm delivery, but others have reported no such association.

A single dose of nevirapine for both the mother and newborn infant lowers the rate of mother-to-child transmission of HIV-1 by more than 40%. Nevertheless, large numbers of both women and infants become resistant to nevirapine when exposed to a single peripartum dose. This prospective observational study was done to assess virologic responses to nevirapine-based antiretroviral treatment in women and infants who had previously been randomly assigned to receive a single peripartum dose of nevirapine or placebo. The major end point for both mothers and infants was virologic failure at the 6-month follow-up visit after initiation of antiretroviral therapy. Of 218 women who began antiretroviral therapy, 112 had received a single dose of nevirapine, and 106, placebo.

IMPORTANCE: Maternal antiretroviral treatment (ART) started before conception may increase the risk for adverse birth outcomes among women with human immunodeficiency virus (HIV) infection, but whether the risk differs by ART regimen is unknown. OBJECTIVE: To compare the risk for selected birth outcomes by maternal ART regimen. DESIGN, SETTING, AND PARTICIPANTS: This observational birth outcomes surveillance study compared all live births and stillbirths with a gestational age of at least 24 weeks in 8 geographically dispersed government hospitals throughout Botswana (approximately 45% of births nationwide). Data were collected from August 15, 2014, through August 15, 2016. EXPOSURES: Births among HIV-infected women who started 3-drug ART regimens before their last menstrual period and did not switch or stop ART in pregnancy were considered to be ART exposed from conception. MAIN OUTCOMES AND MEASURES: The primary outcomes were any adverse birth outcome, including stillbirth, preterm birth (&lt;37 weeks), small size for gestational age (SGA; &lt;10th percentile of weight for gestational age) or neonatal death (&lt;28 days from delivery), and any severe adverse outcome, including very preterm birth (&lt;32 weeks), very SGA (&lt;3rd percentile of weight for gestational age), stillbirth, and neonatal death. RESULTS: Information was available for 47 027 of 47 124 births (99.8%) at surveillance maternity hospitals (mean [SD] age of mothers, 26.86 [6.45] years). Among 11 932 HIV-exposed infants, 5780 (48.4%) were ART exposed from conception. Adverse birth outcomes were more common among HIV-exposed infants than HIV-unexposed infants (39.6% vs 28.9%; adjusted relative risk [ARR], 1.40; 95% CI, 1.36-1.44). The risk for any adverse birth outcome was lower among infants exposed from conception to tenofovir disoproxil fumarate, emtricitabine, and efavirenz (TDF-FTC-EFV) (901 of 2472 [36.4%]) compared with TDF-FTC and nevirapine (NVP) (317 of 760 [41.7%]; ARR, 1.15; 95% CI, 1.04-1.27); TDF-FTC and lopinavir-ritonavir (TDF-FTC–LPV-R) (112 of 231 [48.5%]; ARR, 1.31; 95% CI, 1.13-1.52); zidovudine, lamivudine, and NPV (ZDV-3TC-NVP) (647 of 1365 [47.4%]; ARR, 1.30; 95% CI, 1.20-1.41); or ZDV-3TC–LPV-R (75 of 167 [44.9%]; ARR, 1.21; 95% CI, 1.01-1.45). The risk for any severe adverse outcome was also lower among infants exposed from conception to TDF-FTC-EFV (303 of 2472 [12.3%]) compared with TDF-FTC-NVP (136 of 760 [17.9%]; ARR, 1.44; 95% CI, 1.19-1.74), TDF-FTC–LPV-R (45 of 231 [19.5%]; ARR, 1.58; 95% CI, 1.19-2.11), ZDV-3TC-NVP (283 of 1365 [20.7%]; ARR, 1.68; 95% CI, 1.44-1.96), or ZDV-3TC–LPV-R (39 of 167 [23.4%]; ARR, 1.93; 95% CI, 1.43-2.60) from conception. Compared with TDF-FTC-EFV, all other regimens were associated with higher risk for SGA; ZDV-3TC-NVP was associated with higher risk of stillbirth, very preterm birth, and neonatal death; and ZDV-3TC-LPV-R was associated with higher risk for preterm birth, very preterm birth, and neonatal death. CONCLUSIONS AND RELEVANCE: Among infants exposed to ART from conception, TDF-FTC-EFV was associated with a lower risk for adverse birth outcomes than other ART regimens.