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Visceral leishmaniasis is an endemic infection in Mediterranean countries, where it has become a frequent complication of acquired immunodeficiency syndrome (AIDS). The incidence of visceral leishmaniasis is increasing in Spain due to human immunodeficiency virus (HIV)-related cases, but some aspects of its epidemiology, clinical features, and management remain unknown. In addition, no comparative clinical studies about the disease in HIV-infected and non-HIV-infected patients have been reported. During a 24-year period, 120 cases of visceral leishmaniasis were diagnosed at our institution and 80 (66%) were associated with HIV infection. The mean age at diagnosis was higher in HIV-infected that in non-HIV-infected patients (33.2 versus 23.2 yr; p = 0.002), but the male/female ratio was similar in both groups. The main risk factor for HIV infection was intravenous drug abuse (78.7%). The clinical presentation of leishmaniasis was similar in both groups, but HIV-infected patients had a lower frequency of splenomegaly than HIV-negative individuals (80.8% versus 97.4%; p = 0.02). HIV-infected patients had a greater frequency and degree of leukopenia, lymphocytopenia, and thrombocytopenia. Most of them were profoundly immunosuppressed (mean CD4+ lymphocyte count, 90 cells/mm3) at the time of diagnosis of leishmaniasis, and 53.7% had AIDS. The sensitivity of serologic studies for Leishmania was significantly lower in HIV-infected than in non-HIV-infected patients (50% versus 80%; p < 0.001), but the diagnostic yield of bone marrow aspirate (67.1% versus 79.4%) and bone marrow culture (62.9% versus 66.6%) was similar in both groups. After initial treatment, the response rate was significantly lower in HIV-infected than in non-HIV-infected individuals (54.8% versus 89.7%; p = 0.001). The relapse rate was 46.2% and 7.5%, respectively (p < 0.001). Secondary prophylaxis with antimonial compounds or amphotericin B seems to be useful in preventing relapses in HIV-infected patients. The mortality rate was higher (53.7% versus 7.5%; p < 0.001) and the median survival time shorter (25 versus > 160 mo; p < 0.001) in AIDS patients than in HIV-negative individuals. Although leishmaniasis could contribute to death in a significant number of HIV-infected patients, it was the main cause of death in only a few of them. The CD4+ lymphocyte count and the use of highly active antiretroviral therapy and secondary prophylaxis for leishmaniasis were the most significant prognostic factors for survival in AIDS patients. Visceral leishmaniasis behaves as an opportunistic infection in HIV-infected individuals and should be considered as an AIDS-defining disease.

Forced spirometry is pivotal for diagnosis and management of respiratory diseases, but its use in primary care is suboptimal. The aim of the present study was to assess a web-based application aiming at fostering high-quality spirometry in primary care.This was a randomised controlled trial with 12 intervention primary care units (PCi) and six control units (PCc) studied over 12 months. All 34 naïve nurses (PCi and PCc) received identical training. The PCi units had access to educational material and remote expert support. Quality of spirometry and usability of the web application were assessed.We included 4,581 patients (3,383 PCi and 1,198 PCc). At baseline, quality was similar (PCi 71% and PCc 67% high-quality tests). During the study, PCi showed higher percentage (71.5%) of highquality tests than PCc (59.5%) (p,0.0001). PCi had 73% more chance of high-quality performance than PCc. The web application was better for assessing quality of testing than the automatic feedback provided by the spirometer. Healthcare professionals' satisfaction and usability were high.The web-based remote support for primary care by specialists generated a sustained positive impact on quality of testing. The study expands the potential of primary care for diagnosis and management of patients with pulmonary diseases.

Conclusions-Current concentrations of ambient air pollution in Valencia are significantly associated with emergency room visits for asthma. This association is high and more consistent for NO 2 and O 3 than for particulate matter and SO 2 (classic pollutants). (Occup Environ Med 1998;55:541-547)

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A preclinical evaluation was conducted to evaluate the performance of the Cepheid Xpert assay on 135 lower respiratory tract secretions for detection of methicillin-resistant Staphylococcus aureus and S. aureus. Compared with the quantitative culture, the sensitivity, specificity, and positive and negative predictive values were 99.0%, 72.2%, 90.7%, and 96.3%, respectively. V entilator-associated pneumonia (VAP) is associated with high morbidity and mortality rates (15, 18), particularly in those patients who receive inadequate antimicrobial treatment (8,19). Microbiologic information in patients with suspicion of VAP relies mainly on the quantitative culture of lower respiratory tract (LRT) secretions, and conventional bacterial isolation, identification, and antimicrobial susceptibility testing takes no less than 48 to 72 h. Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA) are important etiologic agents of VAP and account for variable proportions that range from 19.5% to 34.4% of all episodes in different regions (3,4,9). Empirical treatment of VAP in many institutions requires the administration of potentially toxic or costly anti-MRSA antibiotics, such as vancomycin or linezolid.Rapid molecular diagnostic tests for VAP are an unmet medical need recently acknowledged by the Infectious Diseases Society of America (IDSA) (1). In past years, the automated Cepheid Xpert MRSA/SA SSTI real-time PCR assay (Cepheid, Sunnyvale, CA) has been FDA and CE (European Community) approved for the simultaneous detection of methicillin-susceptible S. aureus (MSSA) and MRSA in skin and soft tissue infection swabs and blood cultures (21). This test has also been used directly on perioperative bone and joint samples for the diagnosis of osteoarticular infections (7). The use of the assay for the direct detection of MSSA and MRSA in LRT secretions in the diagnosis of VAP is an off-label use not endorsed by the manufacturer, and to the best of our knowledge, this assay has not yet been evaluated in this setting.We conducted a preclinical comparison of Xpert MRSA/SA assay to the gold standard, the quantitative culture method, in order to evaluate the performance of this assay directly on LRT secretions from patients with suspicion of VAP. Over a period of 15 months, all LRT samples (endotracheal aspirates) received in the microbiology laboratory from patients admitted to the intensive care units (ICUs) of our hospital and suspected of having VAP were examined by Gram stain and routinely cultured onto sheep blood, chocolate, and McConkey agar plates by the standard quantitative culture technique, which was considered the gold standard method. Plates were incubated for 18 to 24 h at 35 Ϯ 2°C aerobically and in 5% CO 2 (chocolate agar) (22). Colony counts of Ն10 4 CFU/ml of either MRSA or MSSA were considered significant and a positive test result (quantitative culture), whereas counts below 10 4 CFU/ml of either MRSA or MSSA were considered a negative test result (qualitative culture) (2). The absence of gro...

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Recurrent bacterial bronchitis should be added to the list of bacterial infections that occur with increased frequency with HIV infection. Repeated bacterial bronchitis may lead to bronchiectasis, which may be more common in HIV infection than generally appreciated.