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1.  Fusobacterium Nucleatum: Atypical Organism of Pyogenic Liver Abscess Might be Related to Sigmoid Diverticulitis 
Context:
Pyogenic liver abscesses (PLAs) are the most common form of liver abscesses in the United States. Most cases are caused by enteric bacteria and anaerobes. We report a case of PLA caused by a rare pathogen, Fusobacterium nucleatum, from an unusual primary site of infection.
Case Report:
A 60-year-old male presented with subacute fever. Initial work-up revealed leukocytosis and elevated alkaline phosphatase (ALP). Dental examination and Panorex x-ray were normal. Imaging of the liver with abdominal computed tomography demonstrated a 5.5 cm abscess in the right lobe of the liver. Culture of the aspirate grew Fusobacterium nucleatum. He improved with abscess drainage and antibiotic therapy with moxifloxacin and metronidazole. Colonoscopy performed a few weeks later, demonstrated sigmoid ulceration most likely from the previous diverticulitis.
Conclusion:
PLAs can be a complication of sigmoid diverticulitis and as a result of occult dental disease as well. The clinical presentation of Fusobacterium infection is diverse and can be fatal if diagnosis is delayed. Therefore, early diagnosis and treatment are the keys to preventing serious complications.
doi:10.4103/1947-2714.179961
PMCID: PMC4866478  PMID: 27213146
Diverticulitis; fusobacterium nucleatum; oral infection; pyogenic liver abscess
2.  Hospitalized Patients' Perceptions of Resident Fatigue, Duty Hours, and Continuity of Care 
Background
Physicians' perceptions of duty hour regulations have been closely examined, yet patient opinions have been largely unstudied to date.
Objective
We studied patient perceptions of residency duty hours, fatigue, and continuity of care following implementation of the Accreditation Council for Graduate Medical Education 2011 Common Program Requirements.
Methods
A cross-sectional survey was administered between June and August 2013 to inpatients at a large academic medical center and an affiliated community hospital. Adult inpatients on teaching medical and surgical services were eligible for inclusion in the study.
Results
Survey response rate was 71.3% (513 of 720). Most respondents (57.1%, 293 of 513) believed residents should not be assigned to shifts longer than 12 hours, and nearly half (49.7%, 255 of 513) wanted to be notified if a resident caring for them had worked longer than 12 hours. Most patients (63.2%, 324 of 513) believed medical errors commonly occurred because of fatigue, and fewer (37.4%, 192 of 513; odds ratio, 0.56; P < .01) believed medical errors commonly occurred as a result of transfers of care. Given the choice between a familiar physician who “may be tired from a long shift” or a “fresh” physician who had received sign-out, more patients chose the fresh but unfamiliar physician (57.1% [293 of 513] versus 42.7% [219 of 513], P < .01).
Conclusions
In a survey about physician attributes relevant to medical errors and patient safety, adult inpatients in a large and diverse sample reported greater concern about fatigue and working hours than about continuity of care.
doi:10.4300/JGME-D-14-00128.1
PMCID: PMC4477557  PMID: 26140114
3.  Longitudinal Anthropometric Patterns Among HIV-infected and –uninfected Women 
Introduction
Previous studies suggest that indicators of central adiposity such as waist-to-hip ratio (WHR) and waist circumference may be altered by HIV infection, antiretroviral (ARV) treatment or both.
Methods
Waist and hip circumference and body mass index (BMI) were measured among participants of the Women’s Interagency HIV Study (WIHS) semiannually from 1999 to 2004. Generalized linear models evaluated longitudinal patterns of these measures and associations with demographic and clinical characteristics.
Results
WHR was significantly larger while BMI, waist and hip circumference were significantly smaller at almost all eleven semiannual visits among 942 HIV-infected compared to 266 HIV-uninfected women. Among HIV-uninfected women, mean waist and hip circumference and BMI increased over the 5 year study period (waist: +4.1 cm or 4.4%, hip: +3.76 cm or 3.5% and BMI +2.43 kg/m2 or 8.2%), while WHR remained stable. Among the HIV-infected women, waist and hip circumference, BMI and WHR did not significantly change.
Independent predictors of smaller BMI among HIV-infected women included White race, HCV seropositivity, current smoking, higher viral load and lower CD4. Independent predictors of larger WHR among HIV-infected women included age, White and Other non-African-American race, higher CD4 and PI use. Use of a HAART regimen was not an independent predictor of either BMI or WHR..
Conclusions
HIV-infected women had higher WHR compared to HIV-uninfected women, despite lower BMI, waist and hip measurements. BMI, waist and hip circumference increased over 5 years among the HIV-uninfected women, but remained stable in the HIV-infected women. Among HIV-infected women, PI use was associated with larger WHR, although HAART use itself was not appreciably associated with either BMI or WHR.
doi:10.1097/QAI.0b013e318162f597
PMCID: PMC4406344  PMID: 18197125
anthropometrics; HIV; women; waist-to-hip ratio
4.  LeFort I Osteotomy 
Seminars in Plastic Surgery  2013;27(3):149-154.
The LeFort I osteotomy is one of the most commonly used procedures to correct midface deformities. It allows for correction in three dimensions including advancement, retrusion, elongation, and shortening. It is indicated, often in conjunction with mandibular surgery, for class II and III malocclusion, facial asymmetry, obstructive sleep apnea, and maxillary atrophy. Before surgery, proper orthodontics and surgical planning should be undertaken to ensure adequate outcomes. Overall, the surgery is widely used due to its low complication profile and reliable long-term results.
doi:10.1055/s-0033-1357112
PMCID: PMC3805729  PMID: 24872761
LeFort I; osteotomy; malocclusion; orthognathic; distraction
5.  Unveiling The Hidden Eagle: Acute Parotitis-Induced Eagle Syndrome 
Context:
A cervicofacial pain and foreign body sensation in pharynx associated with styloid process elongation is called Eagle syndrome. Typically, this syndrome is provoked by tonsillectomy or trauma. We report the first case of acute parotitis-induced Eagle syndrome.
Case Report:
A 65-year-old woman presented with right facial pain. CT scan of neck revealed asymmetric enhancement of the right parotid gland compatible with acute parotitis. All inflammation was resolved with antibiotics. However, the patient complained of pain in right mandibular region out of proportion to inflammation. Review CT found to have an asymmetrically long right styloid process measures. The diagnosis of acute parotitis-induced Eagle syndrome was established.
Conclusion:
Physicians should have a high index of suspicion for Eagle syndrome in patients with atypical neck pain and elongated styloid process since another significant manifestation of Eagle syndrome is carotid artery compression leading to recurrent syncope or stroke.
doi:10.4103/1947-2714.127753
PMCID: PMC3968565  PMID: 24696832
Eagle syndrome; Neck pain; Parotitis
6.  Antiretroviral Therapies Associated with Lipoatrophy in HIV-Infected Women 
AIDS patient care and STDs  2007;21(5):297-305.
We previously demonstrated that HIV infection is associated with peripheral and central lipoatrophy in women. We now describe the association of specific antiretroviral drugs (ARV) with body fat changes over a four-year period from 1999 to 2003. 775 HIV-positive and 205 HIV-negative women in the Women’s Interagency HIV Study with anthropometric measurements, weight, bioelectric impedance analysis and ARV collected semiannually were included in analysis. Exposure to ARV was defined as report of use for 3 consecutive semiannual study visits. The average 6–month change in weight, percent total body fat, and circumference measurements (i.e., hip, waist, chest, arm, and thigh) was compared between those exposed and those unexposed to the specific ARV for any of the same three consecutive visits. Weight, percent total body fat, and hip, waist, thigh, chest, and arm circumferences decreased in HIV-positive women, but increased in HIV-negative women on average for every six-month interval over the 4-year study period. Among the HIV-positive women, didanosine was the only ARV associated with decreases in circumference measures in the hip (−0.65 cm, 95% confidence interval [CI]: −1.18, −0.12), waist (−0.71 cm, 95% CI: −1.37, −0.04), chest (−0.71 cm, 95% CI: −1.17, −0.26), and arm (−0.23 cm, 95% CI: −0.48, 0.03; p = 0.08). These prospective data suggest that fat loss continues to predominate in HIV-positive women and exposure to didanosine for at least 12 months may further worsen fat loss.
doi:10.1089/apc.2006.128
PMCID: PMC3133726  PMID: 17518522
7.  Prevalence and Correlates of Elevated Body Mass Index among HIV-Positive and HIV-Negative Women in the Women's Interagency HIV Study 
AIDS Patient Care and STDs  2009;23(12):1009-1016.
Abstract
Since the introduction of highly active antiretroviral therapy (HAART) and the subsequent increased life expectancy in HIV-infected persons, non-HIV–related diseases have become an important cause of morbidity and mortality. This cross-sectional study reports the prevalence of overweight and obesity, and sociodemographic, psychological, and substance use-related risk factors for elevated body mass index (BMI) among 2157 HIV-seropositive (HIV+) in comparison to 730 HIV-seronegative (HIV−) participants in the Women's Interagency HIV Study (WIHS). Separate univariable and multivariate linear regression analyses were completed for HIV+ and HIV− women. Our study revealed a similar proportion of obesity (body mass index [BMI] ≥30) among HIV+ (33%) and HIV− women (29%) (p = 0.12), as well as comparable median BMI (HIV+: 26.1 versus HIV−: 26.7, p = 0.16). HIV+ compared to HIV− women, respectively, were significantly (p < 0.01) older (median = 35.6 versus. 32.5), but similar (p = 0.97) by race/ethnicity (57% African American, 28% Hispanic, and 15% white for both). In multivariate models for both HIV+ and HIV− women, African American race/ethnicity was significantly (p < 0.05) associated with higher BMI, while higher quality of life score and illicit hard drug use were associated with lower BMI. Additionally, smoking, alcohol use, markers of advanced HIV infection (AIDS diagnosis, elevated HIV viral load, low CD4 count), and a history of antiretroviral therapy use (ART) were also associated with lower BMI among HIV+ women. In conclusion, risk factors for elevated BMI were similar for HIV+ and HIV− women in the WIHS. For HIV+ women, all markers of advanced HIV infection and ART use were additionally associated with lower BMI.
doi:10.1089/apc.2009.0175
PMCID: PMC2832643  PMID: 19909168
8.  Self-Perception of Body Fat Changes and HAART Adherence in the Women’s Interagency HIV Study 
AIDS and behavior  2008;13(1):53-59.
To determine the association of self-perceived fat gain or fat loss in central and peripheral body sites with adherence to highly active antiretroviral therapy (HAART) in HIV-seropositive women. 1,671 women from the Women’s Interagency HIV Study who reported HAART use between April 1999 and March 2006 were studied. Adherence was defined as report of taking HAART ≥ 95% of the time during the prior 6 months. Participant report of any increase or decrease in the chest, abdomen, or upper back in the prior 6 months defined central fat gain and central fat loss, respectively. Report of any increase or decrease in the face, arms, legs or buttocks in the prior 6 months defined peripheral fat gain or peripheral fat loss. Younger age, being African-American (vs. White non-Hispanic), a history of IDU, higher HIV RNA at the previous visit, and alcohol consumption were significant predictors of HAART non-adherence (P <0.05). After multivariate adjustment, self-perception of central fat gain was associated with a 1.5-fold increased odds of HAART non-adherence compared to no change. Perception of fat gain in the abdomen was the strongest predictor of HAART non-adherence when the individual body sites were studied. Women who perceive central fat gain particularly in the abdomen are at risk for decreased adherence to HAART despite recent evidence to suggest that HIV and specific antiretroviral drugs are more commonly associated with fat loss than fat gain.
doi:10.1007/s10461-008-9444-7
PMCID: PMC2902995  PMID: 18688706
Lipodystrophy; HIV; Women; HAART adherence; body image perception
9.  Protease Inhibitor Levels in Hair Samples Strongly Predict Virologic Responses to HIV Treatment 
AIDS (London, England)  2009;23(4):471-478.
Objective
Antiretroviral (ARV) therapies fail when behavioral or biologic factors lead to inadequate medication exposure. Currently available methods to assess ARV exposure are limited. Levels of ARVs in hair reflect plasma concentrations over weeks to months and may provide a novel method for predicting therapeutic responses.
Design/methods
The Women's Interagency HIV Study, a prospective cohort of HIV-infected women, provided the basis for developing and assessing methods to measure commonly-prescribed protease inhibitors (PIs) - lopinavir (LPV) and atazanavir (ATV) - in small hair samples. We examined the association between hair PI levels and initial virologic responses to therapy in multivariate logistic regression models.
Results
ARV concentrations in hair were strongly and independently associated with treatment response for 224 women starting a new PI-based regimen. For participants initiating LPV/RTV, the odds ratio (OR) for virologic suppression was 39.8 (95%CI 2.8–564) for those with LPV hair levels in the top tertile (>1.9ng/mg) compared to the bottom (≤0.41ng/mg) when controlling for self-reported adherence, age, race, starting viral load and CD4, and prior PI experience. For women starting ATV, the adjusted OR for virologic success was 7.7 (95%CI 2.0-29.7) for those with hair concentrations in the top tertile (>3.4ng/mg) compared to the lowest (≤1.2ng/mg).
Conclusions
PI levels in small hair samples were the strongest independent predictor of virologic success in a diverse group of HIV-infected adults. This noninvasive method for determining ARV exposure may have particular relevance for the epidemic in resource-poor settings due to the ease of collecting and storing hair.
doi:10.1097/QAD.0b013e328325a4a9
PMCID: PMC2654235  PMID: 19165084
Hair levels; therapeutic drug monitoring; antiretroviral exposure; virologic response; protease inhibitors; atazanavir; lopinavir; WIHS cohort

Results 1-9 (9)