The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

The optimism of the early period of antimicrobial discovery has been tempered by the emergence of bacterial strains with resistance to these therapeutics. Today, clinically important bacteria are characterized not only by single drug resistance but also by multiple antibiotic resistance--the legacy of past decades of antimicrobial use and misuse. Drug resistance presents an ever-increasing global public health threat that involves all major microbial pathogens and antimicrobial drugs.

/pdf/antibacterial-resistance-worldwide-causes-challenges-and-1cbvr301rt.pdf

Antibacterial resistance worldwide: causes, challenges and responses.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)60206-1.pdf

Global burden of acute lower respiratory infections due to respiratory syncytial virus in young children: a systematic review and meta-analysis

In the past decade, leptospirosis has emerged as a globally important infectious disease. It occurs in urban environments of industrialised and developing countries, as well as in rural regions worldwide. Mortality remains significant, related both to delays in diagnosis due to lack of infrastructure and adequate clinical suspicion, and to other poorly understood reasons that may include inherent pathogenicity of some leptospiral strains or genetically determined host immunopathological responses. Pulmonary haemorrhage is recognised increasingly as a major, often lethal, manifestation of leptospirosis, the pathogenesis of which remains unclear. The completion of the genome sequence of Leptospira interrogans serovar lai, and other continuing leptospiral genome sequencing projects, promise to guide future work on the disease. Mainstays of treatment are still tetracyclines and beta-lactam/cephalosporins. No vaccine is available. Prevention is largely dependent on sanitation measures that may be difficult to implement, especially in developing countries.

https://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(03)00830-2.pdf

Leptospirosis: a zoonotic disease of global importance

These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 18-30, 2009. The information in this report updates the 2006 Guidelines for Treatment of Sexually Transmitted Diseases (MMWR 2006;55[No. RR-11]). Included in these updated guidelines is new information regarding 1) the expanded diagnostic evaluation for cervicitis and trichomoniasis; 2) new treatment recommendations for bacterial vaginosis and genital warts; 3) the clinical efficacy of azithromycin for chlamydial infections in pregnancy; 4) the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitis and treatment-related implications; 5) lymphogranuloma venereum proctocolitis among men who have sex with men; 6) the criteria for spinal fluid examination to evaluate for neurosyphilis; 7) the emergence of azithromycin-resistant Treponema pallidum; 8) the increasing prevalence of antimicrobial-resistant Neisseria gonorrhoeae; 9) the sexual transmission of hepatitis C; 10) diagnostic evaluation after sexual assault; and 11) STD prevention approaches.

Sexually transmitted diseases treatment guidelines, 2010.

Autochthonous dengue infections were last reported in Hawaii in 1944. In September 2001, the Hawaii Department of Health was notified of an unusual febrile illness in a resident with no travel history; dengue fever was confirmed. During the investigation, 1,644 persons with locally acquired denguelike illness were evaluated, and 122 (7%) laboratory-positive dengue infections were identified; dengue virus serotype 1 was isolated from 15 patients. No cases of dengue hemorrhagic fever or shock syndrome were reported. In 3 instances autochthonous infections were linked to a person who reported denguelike illness after travel to French Polynesia. Phylogenetic analyses showed the Hawaiian isolates were closely associated with contemporaneous isolates from Tahiti. Aedes albopictus was present in all communities surveyed on Oahu, Maui, Molokai, and Kauai; no Ae. aegypti were found. This outbreak underscores the importance of maintaining surveillance and control of potential disease vectors even in the absence of an imminent disease threat.

/pdf/dengue-fever-hawaii-2001-2002-3eq949p73r.pdf

Dengue fever, Hawaii, 2001-2002.

Leptospirosis is frequently misdiagnosed as a result of its protean and nonspecific presentation. Leptospirosis, a zoonosis with global distribution, commonly occurs in tropical and subtropical regions; most reported cases in the United States occur in Hawaii. All laboratory-confirmed leptospirosis cases in the State of Hawaii from 1974 through 1998 (n=353) were clinically evaluated. The most common presentation involved nonspecific signs or symptoms, including fever, myalgia, and headache. Jaundice occurred in 39% of cases; conjunctival suffusion was described in 28% of these cases. Initiation of antibiotics before the seventh day of symptoms was associated with a significantly shortened duration of illness. Because early recognition and initiation of antibiotic therapy are important, clinicians should familiarize themselves with the clinical presentation of leptospirosis, and when evaluating a patient with a febrile illness, they should obtain exposure and travel histories and entertain the possibility of leptospirosis in the differential diagnosis.

Assessment of the Clinical Presentation and Treatment of 353 Cases of Laboratory-Confirmed Leptospirosis in Hawaii, 1974–1998

Statewide System of Electronic Notifiable Disease Reporting From Clinical Laboratories

ContextNotifiable disease surveillance is essential to rapidly identify and
respond to outbreaks so that further illness can be prevented. Automating
reports from clinical laboratories has been proposed to reduce underreporting
and delays.ObjectiveTo compare the timeliness and completeness of a prototypal electronic
reporting system with that of conventional laboratory reporting.DesignLaboratory-based reports for 5 conditions received at a state health
department between July 1 and December 31, 1998, were reviewed. Completeness
of coverage for each reporting system was estimated using capture-recapture
methods.SettingThree statewide private clinical laboratories in Hawaii.Main Outcome MeasuresThe number and date of reports received, by reporting system, laboratory,
and pathogen; completeness of data fields.ResultsA total of 357 unique reports of illness were identified; 201 (56%)
were received solely through the automated electronic system, 32 (9%) through
the conventional system only, and 124 (35%) through both. Thus, electronic
reporting resulted in a 2.3-fold (95% confidence interval [CI], 2.0-2.6) increase
in reports. Electronic reports arrived an average of 3.8 (95% CI, 2.6-5.0)
days earlier than conventional reports. Of 21 data fields common to paper
and electronic formats, electronic reports were significantly more likely
to be complete for 12 and for 1 field with the conventional system. The estimated
completeness of coverage for electronic reporting was 80% (95% CI, 77%-82%)
compared with 38% (95% CI, 37%-39%) for the conventional system.ConclusionsIn this evaluation, electronic reporting more than doubled the total
number of laboratory-based reports received. On average, the electronic reports
were more timely and more complete, suggesting that electronic reporting may
ultimately facilitate more rapid and comprehensive institution of disease
control measures.

https://jamanetwork.com/journals/jama/articlepdf/192104/joc90534.pdf

Statewide System of Electronic Notifiable Disease Reporting From Clinical Laboratories: Comparing Automated Reporting With Conventional Methods

Leptospirosis is a major public health problem throughout the world. Clinical recognition of leptospirosis is challenging, and the definitive serologic diagnostic assay, the microscopic agglutination test, is time-consuming and difficult to conduct. Various serologic screening tests have been developed, but their performance among ill persons in the United States has not been established. Eight screening tests were compared using 379 serum samples obtained in 1998 and 1999 from a series of 236 patients (33 with confirmed infection). The median number of days between illness onset and specimen collection was 9. The overall sensitivity, by specimen, for each test was as follows: indirect hemagglutination assay (MRL Diagnostics, Cypress, Calif.), 29%; INDX Leptospira Dip-S-Tick (PanBio InDx, Inc., Baltimore, Md.), 52%; Biognost IgM IFA test (Bios GmbH Labordiagnostik, Grafelfing, Germany), 40%; Biolisa IgM ELISA (Bios GmbH, Labordiagnostik), 48%; Leptospira IgM ELISA (PanBio Pty Ltd., Brisbane, Australia), 36%; SERION ELISA classic Leptospira (Institut Virion*Serion GmbH, Wurzburg, Germany), 48%; LEPTO Dipstick(Organon-Teknika, Ltd., Amsterdam, The Netherlands), 34%; Biosave latex agglutination test (LATEX; Bios GmbH Labordiagnostik), 86%. Test specificity ranged from 85 to 100% among all tests except LATEX, for which the specificity was significantly lower, at 10%. Test sensitivity was particularly low (<25%) for all tests (except LATEX) on specimens collected during the first week of illness. This is the most comprehensive field trial of leptospirosis screening tests reported to date. The data indicate that immunoglobulin M detection tests have limited utility for diagnosing leptospirosis during the initial evaluation of patients seen in Hawaii, a time when important therapeutic decisions are made. Improved leptospirosis screening tests are needed.

Paul V. Effler

Papers

Dengue fever, Hawaii, 2001-2002.

Assessment of the Clinical Presentation and Treatment of 353 Cases of Laboratory-Confirmed Leptospirosis in Hawaii, 1974–1998

Statewide System of Electronic Notifiable Disease Reporting From Clinical Laboratories

Statewide System of Electronic Notifiable Disease Reporting From Clinical Laboratories: Comparing Automated Reporting With Conventional Methods

Evaluation of Eight Rapid Screening Tests for Acute Leptospirosis in Hawaii