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Introduction: In 2021, Jamaica's maternal mortality ratio doubled as a result of COVID-19-related deaths. Yet, COVID-19 vaccination among pregnant Jamaican women remained low. In the United States, COVID-19 vaccination is lower among pregnant women who have had multiple pregnancies (multigravidas) versus women who were pregnant for the first time (primigravidas). We examined whether this pattern exists in Jamaica., Methods: A cross-sectional survey of a convenience sample of 79 pregnant Jamaican women recruited from a teaching hospital (May-July 2022) was used to assess self-reported COVID-19 vaccination and medical mistrust beliefs-operationalized as low vaccine confidence, government mistrust, and race-based mistrust-by gravidity. We used modified Poisson regression to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for vaccination by gravidity, adjusting for age, education, and comorbidities., Results: Thirty-nine (49%) of the participants were multigravidas. Socioeconomic status was similar between multigravidas and primigravidas. COVID-19 vaccination was lower in multigravidas (46%) than primigravidas (75%) after adjusting for age, education, and comorbidities (aPR = 0.67, 95% CI = 0.46-0.99; p = 0.044). Vaccine confidence was lower in multigravidas ( p = 0.044). Government mistrust and race-based mistrust did not differ between the two groups., Conclusion: In Jamaica, multigravidas may have lower COVID-19 vaccine uptake and lower vaccine confidence compared with primigravidas. Understanding the distinct needs of pregnant subpopulations is essential for crafting effective maternal vaccination campaigns., Competing Interests: CONFLICT OF INTEREST STATEMENT The authors declare no conflict of interest.

Infections remain a major concern following bispecific antibody therapy but are not well described in pivotal trials. We present the first well-documented case of a classic but rare opportunistic infection, disseminated Mycobacterium avium complex, in a patient receiving bispecific antibody therapy., Competing Interests: Potential conflicts of interest: A.W.S. reports receiving grants/research support (to the institution) from Replimune, Morphogenesis, Regeneron, and Merck, fees from Natera, Merck, Regeneron, and Leerink, royalties from UpToDate, Inc, and stock ownership in Illumina, Inc. C.J. reports consulting/advisory role for AbbVie, Abintus Bio, ADC Therapeutics, BMS/Celgene, Caribou Bio, Daiichi Sankyo, ImmPACT Bio, Instil Bio, Ipsen, Kite, a Gilead Company, Miltenyi Biotec, MorphoSys, Novartis, and Synthekine, and research funding from Kite, a Gilead Company and Pfizer. The remaining authors declare no competing interests., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: For persons with suspected pulmonary tuberculosis, the guidelines of the Centers for Disease Control and Prevention recommend collecting 3 respiratory specimens 8 to 24 hours apart for acid-fast bacilli (AFB) smear and culture, in addition to 1 nucleic acid amplification test (NAAT). However, data supporting this approach are limited. Our objective was to estimate the performance of 1, 2, or 3 AFB smears with or without NAATs to detect pulmonary tuberculosis in a low-prevalence setting., Methods: We conducted a retrospective study of hospitalized persons at 8 Massachusetts acute care facilities who underwent mycobacterial culture on 1 or more respiratory specimens between July 2016 and December 2022. We evaluated percentage positivity and yield on serial AFB smears and NAATs among people with growth of Mycobacterium tuberculosis on mycobacterial cultures., Results: Among 104 participants with culture-confirmed pulmonary tuberculosis, the first AFB smear was positive in 41 cases (39%). A second AFB smear was positive in 11 (22%) of the 49 cases in which it was performed. No third AFB smears were positive following 2 initial negative smears. Of 52 smear-negative cases, 36 had a NAAT performed, leading to 23 additional diagnoses. Overall sensitivity to detect tuberculosis prior to culture positivity was higher in any strategy involving 1 or 2 NAATs (74%-79%), even without AFB smears, as compared with 3 smears alone (60%)., Conclusions: Tuberculosis diagnostic testing with 2 AFB smears offered the same yield as 3 AFB smears while potentially reducing laboratory burden and duration of airborne infection isolation. Use of 1 or 2 NAATs increased sensitivity to detect culture-positive pulmonary tuberculosis when added to AFB smear-based diagnostic testing alone., Competing Interests: Potential conflicts of interest. J. A. B. has received research funding for other studies from Zeus Scientific, Pfizer, and Analog Devices Inc and has been a paid consultant to Roche Diagnostics, Flightpath Biosciences, and Tarsus Pharmaceuticals. All other authors report no potential conflicts., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Pregnant people with coronavirus disease 2019 (COVID-19) have a higher risk of adverse maternal and fetal outcomes compared with pregnant people without COVID-19. In 2021, large increases in maternal mortality were reported in Jamaica, almost half of which were attributable to COVID-19. COVID-19 vaccination has been shown to reduce these risks, but low- and middle-income countries lack free, publicly available data, known as open data, on COVID-19 vaccine uptake for their pregnant populations. The objectives of this paper were to: review how high-income countries use open data to detect trends in COVID-19 vaccine uptake among pregnant people and develop vaccination distribution strategies; outline barriers to making open data available for maternal COVID-19 vaccination in the Caribbean; and propose a multipronged strategy that would increase the availability of open data on maternal COVID-19 vaccination in the Caribbean. A multipronged strategy to fill the data void would involve: (i) utilizing existing Caribbean maternal immunization data collection entities; (ii) adapting digital software tools to establish maternal electronic immunization registries; and (iii) collaborating with local partners skilled in data analytics. Making open data available for COVID-19 vaccine uptake among pregnant people in the Caribbean could offer substantial benefits, including the development of measurable maternal COVID-19 vaccination goals and the facilitation of vaccine decision-making discussions between providers and pregnant people.

Hawthorn ( Crataegus monogyna Jacq.) and whitebeam ( Sorbus aria (L.) Crantz) are wild species traditionally used as ethnic foods in the Mediterranean area. Their red berries, and mainly the peels, may be used as ingredients due to their color (replacing other synthetic colorants) or functional properties. Some previous studies analyze all edible fruits, but there is very little literature on the composition and properties of the pulpless epidermis of the fruits of C. monogyna and no literature concerning the fruits of S. aria . Total phenolic compounds (TPC) and families of hydroxybenzoic acids, hydroxycinnamic acids, flavonols, and total monomeric anthocyanins were determined in the epidermis of C. monogyna and S. aria fruits. The in vitro antioxidant capacity was also determined using QUENCHER (Quick-Easy-New-CHEap-Reproducible) methodology. Anthocyanins profiles were analyzed in hydroalcoholic extracts through HPLC/MS. C. monogyna fruits presented higher content of TPC than S. aria , with hydroxybenzoic acids (2870.6 mg GAE/100g dw) as the major family, followed by flavonols (771.4 mg QE/100 g dw) and hydroxycinnamic acids (610.3 FAE/100 g dw). Anthocyanins were found in 251.7 mg cyanidin-3-glucoside/100 g dw, characterized by the content of cyanidin- O -hexoxide and peonidin- O -hexoxide. The levels of these compounds correlated with higher values of a* parameter (higher intensity of reddish color). These fruits also showed higher antioxidant capacity by Q-Folin-Ciocalteu and Q-FRAP. S. aria peels had fewer phenolic compounds, particularly anthocyanins (33.7 mg cyanidin-3-glucoside/100 g dw), containing different cyanidin derivatives. From these results, new insights about the composition of the epidermis of these wild fruits are provided, and their potential as ingredients for the food industry is corroborated.

Background: Despite high rates of coronavirus disease 2019 (COVID-19)-related maternal mortality, Jamaica currently has little data on COVID-19 vaccine uptake among pregnant women., Methods: We conducted a cross-sectional, web-based survey of 192 reproductive-aged women in Jamaica from February 1 to 8, 2022. Participants were recruited from a convenience sample of patients, providers, and staff at a teaching hospital. We assessed self-reported COVID-19 vaccination status and COVID-19-related medical mistrust (operationalized as vaccine confidence, government mistrust, and race-based mistrust). We used multivariable modified Poisson regression to test the association between vaccine uptake and pregnancy., Results: Of 192 respondents, 72 (38%) were pregnant. Most (93%) were Black. Vaccine uptake was 35% in pregnant women versus 75% in nonpregnant women. Pregnant women were more likely to cite healthcare providers versus the government as trustworthy sources of COVID-19 vaccine information (65% vs 28%). Pregnancy, low vaccine confidence, and government mistrust were associated with a lower likelihood of COVID-19 vaccination (adjusted prevalence ratio [aPR] = 0.68 [95% confidence interval {CI}, .49-.95], aPR = 0.61 [95% CI, .40-.95], and aPR = 0.68 [95% CI, .52-.89], respectively). Race-based mistrust was not associated with COVID-19 vaccination in the final model., Conclusions: Pregnancy, low vaccine confidence, and government mistrust were associated with a lower likelihood of COVID-19 vaccination among reproductive-aged women in Jamaica. Future studies should evaluate the efficacy of strategies proven to improve maternal vaccination coverage, including standing "opt-out" vaccination orders and collaborative provider and patient-led educational videos tailored for pregnant individuals. Strategies that decouple vaccine messaging from government agencies also warrant evaluation., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Female genital tuberculosis (FGTB) is an important cause of morbidity and infertility worldwide. Mycobacterium tuberculosis most commonly spreads to the genital tract from a focus elsewhere in the body and affects the bilateral fallopian tubes and/or endometrium. Many patients with FGTB have indolent disease and are only diagnosed after evaluation for infertility. Women may present with menstrual irregularities, lower abdominal or pelvic pain, or abnormal vaginal discharge. Given the low sensitivity of diagnostic tests, various composite reference standards are used to diagnose FGTB, including some combination of endoscopic findings, microbiological or molecular testing, and histopathological evidence in gynecological specimens. Early treatment with a standard regimen of a 2-month intensive phase with isoniazid, rifampin, ethambutol, and pyrazinamide, followed by a 4-month continuation phase with isoniazid and rifampin, is recommended to prevent irreversible organ damage. However, even with treatment, FGTB can lead to infertility or pregnancy-related complications, and stigma is pervasive., Competing Interests: Potential conflicts of interest. The authors: No reported conflicts of interest., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Isolation of hospitalized persons under investigation (PUIs) for coronavirus disease 2019 (COVID-19) reduces nosocomial transmission risk. Efficient evaluation of PUIs is needed to preserve scarce healthcare resources. We describe the development, implementation, and outcomes of an inpatient diagnostic algorithm and clinical decision support system (CDSS) to evaluate PUIs., Methods: We conducted a pre-post study of CORAL (COvid Risk cALculator), a CDSS that guides frontline clinicians through a risk-stratified COVID-19 diagnostic workup, removes transmission-based precautions when workup is complete and negative, and triages complex cases to infectious diseases (ID) physician review. Before CORAL, ID physicians reviewed all PUI records to guide workup and precautions. After CORAL, frontline clinicians evaluated PUIs directly using CORAL. We compared pre- and post-CORAL frequency of repeated severe acute respiratory syndrome coronavirus 2 nucleic acid amplification tests (NAATs), time from NAAT result to PUI status discontinuation, total duration of PUI status, and ID physician work hours, using linear and logistic regression, adjusted for COVID-19 incidence., Results: Fewer PUIs underwent repeated testing after an initial negative NAAT after CORAL than before CORAL (54% vs 67%, respectively; adjusted odd ratio, 0.53 [95% confidence interval, .44-.63]; P < .01). CORAL significantly reduced average time to PUI status discontinuation (adjusted difference [standard error], -7.4 [0.8] hours per patient), total duration of PUI status (-19.5 [1.9] hours per patient), and average ID physician work-hours (-57.4 [2.0] hours per day) (all P < .01). No patients had a positive NAAT result within 7 days after discontinuation of precautions via CORAL., Conclusions: CORAL is an efficient and effective CDSS to guide frontline clinicians through the diagnostic evaluation of PUIs and safe discontinuation of precautions., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Immunomodulating therapies for COVID-19 may carry risks of reactivating latent infections in foreign-born people. We conducted a rapid review of infection-related complications of immunomodulatory therapies for COVID-19. We convened a committee of specialists to formulate a screening and management strategy for latent infections in our setting. Dexamethasone, used in severe COVID-19, is associated with reactivation of latent tuberculosis, hepatitis B, and dissemination/hyperinfection of Strongyloides species and should prompt screening and/ or empiric treatment in appropriate epidemiologic contexts. Other immunomodulators used in COVID-19 may also increase risk, including interleukin-6 receptor antagonist (e.g., tocilizumab) and kinase inhibitors. People with specific risk factors should also be screened for HIV, Chagas disease, and endemic mycoses. Racial and ethnic minorities in North America, including foreign-born persons, who receive immunomodulating agents for COVID-19 may be at risk for reactivation of latent infections. We develop a screening and management pathway for such patients., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Among hospitalized persons under investigation for coronavirus disease 2019 (COVID-19), more repeated severe acute respiratory syndrome coronavirus 2 nucleic acid amplification tests (NAATs) after a negative NAAT were positive from lower than from upper respiratory tract specimens (1.9% vs 1.0%, P = .033). Lower respiratory testing should be prioritized among patients displaying respiratory symptoms with moderate-to-high suspicion for COVID-19 after 1 negative upper respiratory NAAT., (© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Many people living with HIV (PLWH) have comorbidities which are risk factors for severe coronavirus disease 2019 (COVID-19) or have exposures that may lead to acquisition of severe acute respiratory distress syndrome coronavirus 2. There are few studies, however, on the demographics, comorbidities, clinical presentation, or outcomes of COVID-19 in people with HIV., Objective: To evaluate risk factors, clinical manifestations, and outcomes in a large cohort of PLWH with COVID-19., Methods: We systematically identified all PLWH who were diagnosed with COVID-19 at a large hospital from 3 March to 26 April 2020 during an outbreak in Massachusetts. We analyzed each of the cases to extract information including demographics, medical comorbidities, clinical presentation, and illness course after COVID-19 diagnosis., Results: We describe a cohort of 36 PLWH with confirmed COVID-19 and another 11 patients with probable COVID-19. Almost 85% of PLWH with confirmed COVID-19 had a comorbidity associated with severe disease, including obesity, cardiovascular disease, or hypertension. Approximately 77% of PLWH with COVID-19 were non-Hispanic Black or Latinx whereas only 40% of the PLWH in our clinic were Black or Latinx. Nearly half of PLWH with COVID-19 had exposure to congregate settings. In addition to people with confirmed COVID-19, we identified another 11 individuals with probable COVID-19, almost all of whom had negative PCR testing., Conclusion: In the largest cohort to date of PLWH and confirmed COVID-19, almost all had a comorbidity associated with severe disease, highlighting the importance of non-HIV risk factors in this population. The racial disparities and frequent link to congregate settings in PLWH and COVID-19 need to be explored urgently.

Current guidelines regarding management of spinal TB are mostly extrapolated from trials on pulmonary disease. Since the British Medical Research Council (BMRC) trials in the 1970s, there are not many good quality studies that substantiate best practice guidelines for the management of this entity. Tuberculous infection of the spine behaves much differently from bacterial osteomyelitis and limited data leads to ambiguity in many cases. Although a few studies have been conducted in patients with spinal TB, most were in the era preceding short course chemotherapy and prior to current radiological and surgical advances. While spinal TB is primarily managed medically, surgical intervention may be needed in certain cases. We discuss areas of uncertainty and challenges that exist with regards to medical treatment, diagnosis, therapeutic endpoints, and a few surgical considerations. Substantial delay in diagnosis continues to be common with this disease even in the developed nations, leading to substantial morbidity. In light of limited evidence, there is an emerging recognition of the need to individualize various aspects of its treatment such as duration, frequency and acknowledging the limitations of various diagnostic and radiological modalities. We aim to consolidate potential areas of research in the diagnosis and management of spinal TB and to revisit the latest published evidence on its redressal., Competing Interests: We have no conflict of interest to declare and have adhered to ethical guidelines., (© 2020 The Authors.)

Mycobacterium abscessus disease is particularly challenging to treat, given the intrinsic drug resistance of this species and the limited data on which recommendations are based, resulting in a greater reliance on expert opinion. We address several commonly encountered questions and management considerations regarding pulmonary Mycobacterium abscessus disease, including the role of subspecies identification, diagnostic criteria for determining disease, interpretation of drug susceptibility test results, approach to therapy including the need for parenteral antibiotics and the role for new and repurposed drugs, and the use of adjunctive strategies such as airway clearance and surgical resection.

Although less common as causes of musculoskeletal infection than pyogenic bacteria, both Mycobacterium tuberculosis and nontuberculous mycobacteria can infect bones and joints. Although tuberculous arthritis and osteomyelitis have been recognized for millennia, infections caused by nontuberculous mycobacteria are being identified more often, likely because of a more susceptible host population and improvements in diagnostic capabilities. Despite advances in modern medicine, mycobacterial infections of the musculoskeletal system remain particularly challenging to diagnose and manage. This article discusses clinical manifestations of musculoskeletal infections caused by Mycobacterium tuberculosis and nontuberculous mycobacteria. Pathogenesis, unique risk factors, and diagnostic and therapeutic approaches are reviewed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose of Review: This review aims to describe the key principles in treatment of drug-resistant tuberculosis (TB) in people living with HIV, including early access to timely diagnostics, linkage into care, TB treatment strategies including the use of new and repurposed drugs, co-management of HIV disease, and treatment complications and programmatic support to optimize treatment outcomes. These are necessary strategies to decrease the likelihood of poor treatment outcomes including lower treatment completion rates and higher mortality., Recent Findings: Diagnosis of drug-resistant TB is the gateway into care; yet understanding the utility and the limitations of genotypic methods in this population is necessary. The principles of TB treatment in HIV-infected individuals are similar to those without HIV co-infection, with few exceptions. However, adverse effects with potential significant morbidity may emerge during treatment, and timely antiretroviral therapy is essential to improve mortality in this patient population. Emerging data on the use of new and repurposed drugs and short course multidrug-resistant TB regimens and adherence strategies benefiting this population are reviewed., Summary: The clinical complexity of co-managing drug-resistant TB and HIV, and the higher rate of poor treatment outcomes in this population demand careful clinical management strategies, and multidisciplinary and comprehensive programmatic interventions to optimize treatment success in this vulnerable group.

Purpose of Review: Non-tuberculous mycobacterial [NTM] infections in the hospital setting are a complex and often challenging entity. The goal of this review is to discuss diagnostic and treatment strategies for established as well as emerging nosocomial NTM infections., Recent Findings: NTM outbreaks have been documented in a variety of hospital settings. Contamination of medical devices or aqueous solutions is often implicated in the spread of infection. More recently, the slow grower M. chimaera has been reported in the setting of contaminated heater-cooler devices used for cardiopulmonary bypass and extracorporeal membrane oxygenation. In addition, increases in medical tourism for cosmetic surgery have led to outbreaks of rapidly growing mycobacteria., Summary: Diagnosis and treatment of nosocomial NTM pose many challenges for the clinician. Surgical resection or debridement as well as combination antimycobacterial therapy are a mainstay in therapeutic management. Strict infection control and prevention practices are critical to the identification and cessation of outbreaks., Competing Interests: Conflict of Interest Dr. Desai and Dr. Hurtado declare that they have no conflicts of interest.

Although less common as causes of musculoskeletal infection than pyogenic bacteria, both Mycobacterium tuberculosis and nontuberculous mycobacteria can infect bones and joints. Although tuberculous arthritis and osteomyelitis have been recognized for millennia, infections caused by nontuberculous mycobacteria are being identified more often, likely because of a more susceptible host population and improvements in diagnostic capabilities. Despite advances in modern medicine, mycobacterial infections of the musculoskeletal system remain particularly challenging to diagnose and manage. This article discusses clinical manifestations of musculoskeletal infections caused by Mycobacterium tuberculosis and nontuberculous mycobacteria. Pathogenesis, unique risk factors, and diagnostic and therapeutic approaches are reviewed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A 26-year-old female from India presented with progressive, unremitting low back pain for over 1 year. She had been treated unsuccessfully for left-sided sacroiliitis, pelvic floor dysfunction, ankylosing spondylitis and seronegative spondyloarthritis. MRI lumbar spine showed a Schmorl node with surrounding marrow oedema at L4, the relevance of which is not clear in literature. One year after initial presentation, a biopsy of this lesion revealed culture positive diagnosis of spinal tuberculosis. Despite advances in imaging, delayed diagnosis is not uncommon in spinal tuberculosis (TB). In our case, it was also attributed to an unknown early lesion: Schmorl node with surrounding oedema. Any association of this lesion with spinal TB has previously not been reported., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: In Africa, fewer than half of patients receiving therapy for multidrug-resistant TB (MDR TB) are successfully treated, with poor outcomes reported for HIV-coinfected patients., Methods: A standardised second-line drug (SLD) regimen was used in a non-governmental organisation-Ministry of Health (NGO-MOH) collaborative community and hospital-based programme in Ethiopia that included intensive side effect monitoring, adherence strategies and nutritional supplementation. Clinical outcomes for patients with at least 24 months of follow-up were reviewed and predictors of treatment failure or death were evaluated by Cox proportional hazards models., Results: From February 2009 to December 2014, 1044 patients were initiated on SLD. 612 patients with confirmed or presumed MDR TB had ≥ 24 months of follow-up, 551 (90.0%) were confirmed and 61 (10.0%) were suspected MDR TB cases. 603 (98.5%) had prior TB treatment, 133 (21.7%) were HIV coinfected and median body mass index (BMI) was 16.6. Composite treatment success was 78.6% with 396 (64.7%) cured, 85 (13.9%) who completed treatment, 10 (1.6%) who failed, 85 (13.9%) who died and 36 (5.9%) who were lost to follow-up. HIV coinfection (adjusted HR (AHR): 2.60, p<0.001), BMI (AHR 0.88/kg/m(2), p=0.006) and cor pulmonale (AHR 3.61, p=0.003) and confirmed MDR TB (AHR 0.50, p=0.026) were predictive of treatment failure or death., Conclusions: We report from Ethiopia the highest MDR TB treatment success outcomes so far achieved in Africa, in a setting with severe resource constraints and patients with advanced disease. Intensive treatment of adverse effects, nutritional supplementation, adherence interventions and NGO-MOH collaboration were key strategies contributing to success. We argue these approaches should be routinely incorporated into programmes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

The prevalence of bovine cysticercosis was established using routine postmortem inspection of 52,322 feedlot cattle slaughtered at 1 Federal Inspection Type abattoir (TIF 301) located in the Mexicali Valley in Baja California, México. The study included 31,393 animals (60.0%) purchased and transported to Baja California from stocker operations located in 17 states of México and 20,929 animals (40.0%) native to Baja California. A total of 208 carcasses showed lesions suggestive of cysticercosis, and 109 were confirmed as positive for the parasite with a prevalence of 0.21%, equivalent to 2.1 cases/1000 carcasses inspected, 2.8 cases/1000 carcasses for cattle purchased in other states, and 1.0 cases/1000 carcasses for cattle native from Baja California. The sensitivity of the postmortem inspection, when compared to a gold standard of stereoscopic microscopy, was 52.4%. The prevalence of cysticercosis was 2.8 times higher in cattle from other states compared with those native to Baja California. Cysticerci were most frequently found in the heart, followed by liver and masseter muscles. In cattle from other states, 96.6% of cysticerci were classified as calcified and <4% as viable; in cattle native to Baja California, 29% of cysticerci were classified as calcified and 71% as viable. The prevalence of bovine cysticercosis established at TIF 301 was found to be 28% lower than a previous report for Baja California. However, given the sensitivity of the postmortem inspection calculated between 10% and 50%, it is possible that an undetermined number of carcasses pass as being free of cysticerci and that the meat reached both domestic and international wholesale markets, increasing the possibility of human infection and causing substantial economic loss through condemnation of infected meat and trade restrictions for endemic regions.

Sputum cultures are an important tool in monitoring the response to tuberculosis treatment, especially in multidrug-resistant tuberculosis. There has, however, been little study of the effect of treatment regimen composition on culture conversion. Well-designed clinical trials of new anti-tuberculosis drugs require this information to establish optimized background regimens for comparison. We conducted a retrospective cohort study to assess whether the use of an aggressive multidrug-resistant tuberculosis regimen was associated with more rapid sputum culture conversion. We conducted Cox proportional-hazards analyses to examine the relationship between receipt of an aggressive regimen for the 14 prior consecutive days and sputum culture conversion. Sputum culture conversion was achieved in 519 (87.7%) of the 592 patients studied. Among patients who had sputum culture conversion, the median time to conversion was 59 days (IQR: 31-92). In 480 patients (92.5% of those with conversion), conversion occurred within the first six months of treatment. Exposure to an aggressive regimen was independently associated with sputum culture conversion during the first six months of treatment (HR: 1.36; 95% CI: 1.10, 1.69). Infection with human immunodeficiency virus (HR 3.36; 95% CI: 1.47, 7.72) and receiving less exposure to tuberculosis treatment prior to the individualized multidrug-resistant tuberculosis regimen (HR: 1.58; 95% CI: 1.28, 1.95) were also independently positively associated with conversion. Tachycardia (HR: 0.77; 95% CI: 0.61, 0.98) and respiratory difficulty (HR: 0.78; 95% CI: 0.62, 0.97) were independently associated with a lower rate of conversion. This study is the first demonstrating that the composition of the multidrug-resistant tuberculosis treatment regimen influences the time to culture conversion. These results support the use of an aggressive regimen as the optimized background regimen in trials of new anti-TB drugs.

Double pylorus and gastroduodenal fistula are rare conditions and can be either congenital or acquired. We report a case of a 58-year-old man with epigastric pain and dyspepsia in which the upper gastrointestinal endoscopy revealed an acquired double pylorus, probably caused by a gastric ulcer.

Rationale: A better understanding of the composition of optimal treatment regimens for multidrug-resistant tuberculosis (MDR-TB) is essential for expanding universal access to effective treatment and for developing new therapies for MDR-TB. Analysis of observational data may inform the definition of an optimized regimen., Objectives: This study assessed the impact of an aggressive regimen-one containing at least five likely effective drugs, including a fluoroquinolone and injectable-on treatment outcomes in a large MDR-TB patient cohort., Methods: This was a retrospective cohort study of patients treated in a national outpatient program in Peru between 1999 and 2002. We examined the association between receiving an aggressive regimen and the rate of death., Measurements and Main Results: In total, 669 patients were treated with individualized regimens for laboratory-confirmed MDR-TB. Isolates were resistant to a mean of 5.4 (SD 1.7) drugs. Cure or completion was achieved in 66.1% (442) of patients; death occurred in 20.8% (139). Patients who received an aggressive regimen were less likely to die (crude hazard ratio [HR]: 0.62; 95% CI: 0.44,0.89), compared to those who did not receive such a regimen. This association held in analyses adjusted for comorbidities and indicators of severity (adjusted HR: 0.63; 95% CI: 0.43,0.93)., Conclusions: The aggressive regimen is a robust predictor of MDR-TB treatment outcome. TB policy makers and program directors should consider this standard as they design and implement regimens for patients with drug-resistant disease. Furthermore, the aggressive regimen should be considered the standard background regimen when designing randomized trials of treatment for drug-resistant TB.

The management of children with drug-resistant tuberculosis (DR-TB) is challenging, and it is likely that in many places, the roll-out of molecular diagnostic testing will lead to more children being diagnosed. There is a limited evidence base to guide optimal treatment and follow-up in the pediatric population; in existing DR-TB guidelines, the care of children is often relegated to small "special populations" sections. This article seeks to address this gap by providing clinicians with practical advice and guidance. This is achieved through review of the available literature on pediatric DR-TB, including research studies and international guidelines, combined with consensus opinion from a team of experts who have extensive experience in the care of children with DR-TB in a wide variety of contexts and with varying resources. The review covers treatment initiation, regimen design and treatment duration, management of comorbid conditions, treatment monitoring, adverse events, adherence promotion, and infection control, all within a multidisciplinary environment.

Natalizumab (Tysabri, Biogen Idec and Elan Pharmaceuticals) is a monoclonal antibody approved for use in patients with relapsing multiple sclerosis (MS) as well as moderate to severe Crohn's disease. We report the first case of a patient with a history of MS, on monthly natalizumab, who developed HSV-2 meningitis. We discuss the mechanism of action of natalizumab and review what is known about the reactivation of herpes infection in association with this medication. The question of herpes simplex virus (HSV) and varicella zoster virus (VZV) prophylaxis for patients is raised.

Background: Extensively drug-resistant tuberculosis has been reported in 45 countries, including countries with limited resources and a high burden of tuberculosis. We describe the management of extensively drug-resistant tuberculosis and treatment outcomes among patients who were referred for individualized outpatient therapy in Peru., Methods: A total of 810 patients were referred for free individualized therapy, including drug treatment, resective surgery, adverse-event management, and nutritional and psychosocial support. We tested isolates from 651 patients for extensively drug-resistant tuberculosis and developed regimens that included five or more drugs to which the infecting isolate was not resistant., Results: Of the 651 patients tested, 48 (7.4%) had extensively drug-resistant tuberculosis; the remaining 603 patients had multidrug-resistant tuberculosis. The patients with extensively drug-resistant tuberculosis had undergone more treatment than the other patients (mean [+/-SD] number of regimens, 4.2+/-1.9 vs. 3.2+/-1.6; P<0.001) and had isolates that were resistant to more drugs (number of drugs, 8.4+/-1.1 vs. 5.3+/-1.5; P<0.001). None of the patients with extensively drug-resistant tuberculosis were coinfected with the human immunodeficiency virus (HIV). Patients with extensively drug-resistant tuberculosis received daily, supervised therapy with an average of 5.3+/-1.3 drugs, including cycloserine, an injectable drug, and a fluoroquinolone. Twenty-nine of these patients (60.4%) completed treatment or were cured, as compared with 400 patients (66.3%) with multidrug-resistant tuberculosis (P=0.36)., Conclusions: Extensively drug-resistant tuberculosis can be cured in HIV-negative patients through outpatient treatment, even in those who have received multiple prior courses of therapy for tuberculosis., (2008 Massachusetts Medical Society)

Kaposi's sarcoma in human immunodeficiency virus (HIV) -infected women, often misdiagnosed, has an aggressive clinical course, with high rates of visceral involvement and decreased survival. We describe the first case of isolated pulmonary Kaposi's sarcoma in pregnancy. A nulliparous woman was diagnosed with AIDS after presenting at 25 weeks gestation with a cough and multiple pulmonary nodules. Extensive pulmonary evaluation was nondiagnostic until thorascopic lung biopsy revealed Kaposi's sarcoma. Despite combination antiretroviral therapy, her malignancy progressed. Labor was induced at 33.5 weeks gestation for nonreassuring fetal testing. She received chemotherapy postpartum and remains in remission. Pulmonary Kaposi's sarcoma should be considered in the differential diagnosis of HIV-infected obstetric patients with respiratory compromise. Definitive diagnosis is necessary given the aggressive clinical course that is potentially responsive to therapy.

A case of an intraarticular epithelioid sarcoma is presented. The patient was a 35 year old man who presented with a 10 months history of a chronic monoarthritis. The MRI showed a diffuse lesion involving the synovial membrane of the knee. There was a marked increased signal on T2 weighted images. Most epithelioid sarcomas involve the subcutaneous tissues of the hands or feet. This presentation is unusual and this entity should be considered in the differential diagnosis of an intraarticular proliferative process.