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Some of the serious side effects of childbirth are described for women in the critical postpartum period in developing countries. These side effects include hemorrhage, anemia, nutrition deficits, infection, family violence, and emotional problems. The postpartum period applies to 42 days after delivery, and it is a time when the healing and return of the reproductive organs to their nonpregnant state occurs. During this time, women should receive extra rest, food, and supplementation. In developing countries, maternal mortality primarily occurs during the puerperium. A study in Bangladesh found that 60% of women die during the postpartum period compared to 20% during pregnancy. Women tend to ignore their health problems in general, and, after the birth of a child, there is a tendency to focus on the newborn. A study in the UK revealed that 50% of women with children have longterm maternal health problems related to childbirth. Most postpartum complications are due to hemorrhage and infection. Normal blood loss after delivery is about 150 ml with a range of 300 ml for heavy loss and 500 ml for postpartum hemorrhage. An Australian study showed that 17% lose 500 ml of blood during delivery, and 4% lose more than 1000 ml. Excessive blood loss is directly related to a risk of anemia, and anemic women are at the highest risk of maternal mortality. The physical condition of women is the most significant feature in determining the seriousness of blood loss. A moderate level of blood loss with anemia is dangerous. Anemia leads to chronic fatigue and increased susceptibility to infection. Assuring high nutritional intake (iron and calcium fortified diets) during the postpartum period counteracts anemia and provides calories for adequate milk production. Adequate nutrition during the pregnancy means storage of nutrients for the postpartum period. Some cultures prescribe food restrictions which can impact deleteriously on women's health. Complications or prolonged delivery often lead to sepsis or infection. Infections may occur with improperly healing of tears. Violence against women can occur due to a stillbirth or failure to produce a male heir. Little is known about maternal stress and depression among postpartum women in developing countries.
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PMID:Postpartum care is crucial for health and survival. 1234 57

The guidance in this report is for evaluation and treatment of patients with complications from smallpox vaccination in the preoutbreak setting. Information is also included related to reporting adverse events and seeking specialized consultation and therapies for these events. The frequencies of smallpox vaccine-associated adverse events were identified in studies of the 1960s. Because of the unknown prevalence of risk factors among today's population, precise predictions of adverse reaction rates after smallpox vaccination are unavailable. The majority of adverse events are minor, but the less-frequent serious adverse reactions require immediate evaluation for diagnosis and treatment. Agents for treatment of certain vaccine-associated severe adverse reactions are vaccinia immune globulin (VIG), the first-line therapy, and cidofovir, the second-line therapy. These agents will be available under Investigational New Drug (IND) protocols from CDC and the U.S. Department of Defense (DoD). Smallpox vaccination in the preoutbreak setting is contraindicated for persons who have the following conditions or have a close contact with the following conditions: 1) a history of atopic dermatitis (commonly referred to as eczema), irrespective of disease severity or activity; 2) active acute, chronic, or exfoliative skin conditions that disrupt the epidermis; 3) pregnant women or women who desire to become pregnant in the 28 days after vaccination; and 4) persons who are immunocompromised as a result of human immunodeficiency virus or acquired immunodeficiency syndrome, autoimmune conditions, cancer, radiation treatment, immunosuppressive medications, or other immunodeficiencies. Additional contraindications that apply only to vaccination candidates but do not include their close contacts are persons with smallpox vaccine-component allergies, women who are breastfeeding, those taking topical ocular steroid medications, those with moderate-to-severe intercurrent illness, and persons aged < 18 years. In addition, history of Darier disease is a contraindication in a potential vaccinee and a contraindication if a household contact has active disease. In the event of a smallpox outbreak, outbreak-specific guidance will be disseminated by CDC regarding populations to be vaccinated and specific contraindications to vaccination. Vaccinia can be transmitted from a vaccinee's unhealed vaccination site to other persons by close contact and can lead to the same adverse events as in the vaccinee. To avoid transmission of vaccinia virus (found in the smallpox vaccine) from vaccinees to their close contacts, vaccinees should wash their hands with warm soapy water or hand rubs containing > or = 60% alcohol immediately after they touch their vaccination site or change their vaccination site bandages. Used bandages should be placed in sealed plastic bags and can be disposed of in household trash. Smallpox vaccine adverse reactions are diagnosed on the basis of clinical examination and history, and certain reactions can be managed by observation and supportive care. Adverse reactions that are usually self-limited include fever, headache, fatigue, myalgia, chills, local skin reactions, nonspecific rashes, erythema multiforme, lymphadenopathy, and pain at the vaccination site. Other reactions are most often diagnosed through a complete history and physical and might require additional therapies (e.g., VIG, a first-line therapy and cidofovir, a second-line therapy). Adverse reactions that might require further evaluation or therapy include inadvertent inoculation, generalized vaccinia (GV), eczema vaccinatum (EV), progressive vaccinia (PV), postvaccinial central nervous system disease, and fetal vaccinia. Inadvertent inoculation occurs when vaccinia virus is transferred from a vaccination site to a second location on the vaccinee or to a close contact. Usually, this condition is self-limited and no additional care is needed. Inoculations of the eye and eyelid require evaluation by an ophthalmologist and might require therapy with topical antiviral or antibacterial medications, VIG, or topical steroids. GV is characterized by a disseminated maculopapular or vesicular rash, frequently on an erythematous base, which usually occurs 6-9 days after first-time vaccination. This condition is usually self-limited and benign, although treatment with VIG might be required when the patient is systemically ill or found to have an underlying immunocompromising condition. Infection-control precautions should be used to prevent secondary transmission and nosocomial infection. EV occurs among persons with a history of atopic dermatitis (eczema), irrespective of disease severity or activity, and is a localized or generalized papular, vesicular, or pustular rash, which can occur anywhere on the body, with a predilection for areas of previous atopic dermatitis lesions. Patients with EV are often systemically ill and usually require VIG. Infection-control precautions should be used to prevent secondary transmission and nosocomial infection. PV is a rare, severe, and often fatal complication among persons with immunodeficiencies, characterized by painless progressive necrosis at the vaccination site with or without metastases to distant sites (e.g., skin, bones, and other viscera). This disease carries a high mortality rate, and management of PV should include aggressive therapy with VIG, intensive monitoring, and tertiary-level supportive care. Anecdotal experience suggests that, despite treatment with VIG, persons with cell-mediated immune deficits have a poorer prognosis than those with humoral deficits. Infection-control precautions should be used to prevent secondary transmission and nosocomial infection. Central nervous system disease, which includes postvaccinial encephalopathy (PVE) and postvaccinial encephalomyelitis (or encephalitis) (PVEM), occur after smallpox vaccination. PVE is most common among infants aged < 12 months. Clinical symptoms of central nervous system disease indicate cerebral or cerebellar dysfunction with headache, fever, vomiting, altered mental status, lethargy, seizures, and coma. PVE and PVEM are not believed to be a result of replicating vaccinia virus and are diagnoses of exclusion. Although no specific therapy exists for PVE or PVEM, supportive care, anticonvulsants, and intensive care might be required. Fetal vaccinia, resulting from vaccinial transmission from mother to fetus, is a rare, but serious, complication of smallpox vaccination during pregnancy or shortly before conception. It is manifested by skin lesions and organ involvement, and often results in fetal or neonatal death. No known reliable intrauterine diagnostic test is available to confirm fetal infection. Given the rarity of congenital vaccinia among live-born infants, vaccination during pregnancy should not ordinarily be a reason to consider termination of pregnancy. No known indication exists for routine, prophylactic use of VIG in an unintentionally vaccinated pregnant woman; however, VIG should not be withheld if a pregnant woman develops a condition where VIG is needed. Other less-common adverse events after smallpox vaccination have been reported to occur in temporal association with smallpox vaccination, but causality has not been established. Prophylactic treatment with VIG is not recommended for persons or close contacts with contraindications to smallpox vaccination who are inadvertently inoculated or exposed. These persons should be followed closely for early recognition of adverse reactions that might develop, and clinicians are encouraged to enroll these persons in the CDC registry by calling the Clinician Information Line at 877-554-4625. To request clinical consultation and IND therapies for vaccinia-related adverse reactions for civilians, contact your state health department or CDC's Clinician Information Line (877-554-4625). Clinical evaluation tools are available at http.//www.bt.cdc.gov/agent/smallpox/vaccination/clineval. Clinical specimen-collection guidance is available at http://www.bt.cdc.gov/agent/smallpox/vaccination/vaccinia-specimen-collection.asp. Physicians at military medical facilities can request VIG or cidofovir by calling the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) at 301-619-2257 or 888-USA-RIID.
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PMID:Smallpox vaccination and adverse reactions. Guidance for clinicians. 1261 10

Macrophage activation syndrome MAS describes the clinical, biological and histological symptoms related to a probably T lymphocytes/NK cell driven stimulation of macrophages with the consequence of a hemophagocytosis involving numerous organs, preferentially bone marrow, explaining the other term of "hemophagocytic syndrome". Clinical symptoms include cytopenia, multiple organ dysfunction, fever unresponsive to antibiotics, fatigue and rash. Infections (bacteria, virus or parasites), lymphoproliferative disorders, cancers, systemic diseases are the most prevalent triggers or etiologies of M.A.S. Evidence of haemaphagocytosis is obtained in the majority of cases with bone marrow specimens. In some cases haemophagocytosis can spare the bone marrow with involvement confined to other tissues such as liver and spleen. Very high levels of ferritine seem to correlate well with the presence of haemophagocytosis and is a possible marker for an early diagnosis. Early treatment initiation is mandatory. Corticosteroids, cytostatic drugs such as etoposide, cyclosporine A, plasmapherese, intravenous immunoglobulins and anti TNFalpha are proposed but no randomized trials were published.
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PMID:[Macrophage activation syndrome, hemophagocytic syndrome]. 1533 34

Respiratory viruses were identified by the polymerase chain reaction (PCR) in more than 4,200 specimens collected during 2002 and 2003 in Victoria, Australia from patients admitted to hospitals or participating in an influenza surveillance program. Influenza viruses and picornaviruses were important causes of morbidity in both years. Additional testing of picornavirus-positive samples suggested that rhinoviruses but not enteroviruses were more likely to be associated with respiratory symptoms, irrespective of the season in which they circulated. Detection of influenza viruses was strongly associated with the clinical symptoms of cough, fever, and fatigue; but each of the other respiratory viruses occasionally caused these symptoms or was responsible for symptoms severe enough to require hospitalization. Human coronaviruses HCoV-OC43 and HCoV-229E circulated at low levels throughout the study period with peak activity in winter, but overall did not circulate as widely as has often been reported for these agents. Evidence for the human metapneumovirus (hMPV) was only sought in the second year of the study and revealed low-level circulation of this virus, mainly in the cooler months among the very young and adult populations. The detection rate of all viruses declined with increasing age of the patient, particularly in hospital patients. Infection with more than one respiratory virus occurred in a small number of patients; picornaviruses were most commonly implicated in these dual infections.
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PMID:Laboratory diagnosis and surveillance of human respiratory viruses by PCR in Victoria, Australia, 2002-2003. 1554 80

Effective methods to diminish the burden of hepatitis C virus (HCV) infection among injection drug users (IDUs) require consideration of the epidemiology and natural history of both hepatitis C and drug use. Most HCV infections are due to injection drug use, and most IDUs have HCV infection. In addition, HCV infection often occurs with other medical problems, such as human immunodeficiency virus infection and depression, which may complicate its recognition and management. Infection with HCV can be fatal, but usually not until years later, and persons may be unaware of the infection, allowing an individual to infect many others. Effective treatment is available for HCV infection; however, the therapy is prolonged, involving both weekly injections and daily oral medication, and is typically associated with significant adverse effects, such as fatigue, depression, and, rarely, life-threatening complications. Although clearly some IDUs want their HCV infection to be treated, many are unwilling or unable to initiate or sustain treatment with currently available therapies, and IDUs who are treated require considerable, multidimensional support. Solutions to the problem of HCV infection among IDUs must account for these facts.
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PMID:Epidemiology and natural history of hepatitis C virus infection in injection drug users: implications for treatment. 1576 33

Whipple's disease is a rare chronic multi-systemic infectious disorder caused by the Gram-positive bacillus, Tropheryma whippelii. Infection may involve any organ in the body, and most commonly affects white men in the fourth to sixth decades of life. The most common presenting symptoms are gastrointestinal and include abdominal pain, diarrhoea, anorexia and associated weight loss. However, the variability in presentation is considerable and some patients may present with intermittent low-grade fever, neurological abnormalities (nystagmus, ophthalmoplegia, cranial nerve defects), migratory arthralgia, lymphadenopathy, or involvement of the cardiovascular system. In typical Whipple's disease, the most severe changes are seen in the proximal small intestine and biopsy reveals mucosal and lymph node infiltration with large, foamy histocytes, containing granules that stain positive with periodic acid-Schiff (PAS) reagent and represent intact or partially degraded bacteria. Extended antibiotic treatment (up to 1-year) is indicated. Life-long surveillance for recurrence is essential, once primary treatment has been completed. We report the case of a 58-year-old man who developed a rare infection with the actinobacterium, T. whippelii. The patient had suffered intermittent episodes of varying clinical symptoms associated with multiple hospital admissions and clinical diagnoses, spanning a period of 22 years. Historically, arthralgia was the primary manifestation in this patient and also was the chief complaint for which he was first hospitalized 22 years ago. At his most recent admission to our hospital department, his presenting symptoms were persistent fatigue, weight loss, arthralgia and diarrhoea. Thus, it is essential that clinicians retain a high index of suspicion for T. whippelii infection in patients who have a long-term history of arthritis, fever and diarrhoea.
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PMID:Whipple's disease: multiple hospital admissions of a man with diarrhoea, fever and arthralgia. 1603 47

Malignant brain tumors and the therapies used to treat them can present challenging problems. Headache is the most common symptom during brain tumor illness. Etiology determines the exact management approach, but pharmacologic and non pharmacologic measures may be used. Seizures also commonly occur and are best managed with anti epileptic drug therapy. Infection and deep venous thrombosis are concerns and are best approached by preventive measures and early aggressive intervention if those measures fail. Depression, fatigue, memory and personality changes may complicate care and are approached on an individual basis. Early discussion about end-of-life issues is necessary because the disease itself can impair decision-making ability.
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PMID:Managing symptoms and side effects during brain tumor illness. 1627 64

Babesiosis is caused by a haemotropic protozoal parasite of the genus Babesia, member of the phylum Apicomplexa and transmitted by the bite of an infected tick. There are many Babesia species affecting livestock, dogs, horses and rodents which are of economic significance. Infections can occur without producing symptoms, but babesiosis may also be severe and sometimes fatal caused by the intraerythrocytic parasite development. The disease can cause fever, fatigue and haemolytic anemia lasting from several days to several months. There are a number of effective babesiacides, but imidocarb dipropionate (which consistently clears the parasitaemia; often the only available drug on the market) and diminazene aceturate are the most widely used. Some Babesia spp. can infect humans, particularly Babesia microti and Babesia divergens, and human babesiosis is a significant emerging tick-borne zoonotic disease. Clinical manifestations differ markedly between European and North American diseases. In clinical cases, a combination of clindamycin and quinine is administered as the standard treatment, but also administration of atovaquone-azithromycin is successful. Supportive therapy such as intravenous fluids and blood transfusions are employed when necessary. More specific fast-acting new treatments for babesiosis have now to be developed. This should be facilitated by the knowledge of the Babesia spp. genome and increased interest for this malaria-like parasite.
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PMID:Chemotherapy against babesiosis. 1650 2

Chronic lymphocytic leukemia (CLL), which is the most common leukemia in adult population in the Western world, is surprisingly rare in Thailand. The objective of our study was to retrospectively analyze the clinical presentations and outcome of a large cohort of Thai CLL patients diagnosed at a single institution in Bangkok, Thailand, from 1963-1998. One hundred and eighty-four patients were included in the study. The most frequent age group was 60-80 years old with the male to female ratio of 2:1. Only 12% of patients were younger than the age of 50. Most patients were from the central agricultural region of Thailand. Clinical findings at presentation included splenomegaly (64%), lymphadenopathy (60%), anemia (54%), hepatomegaly (49%), fatigue (39%), weight loss (33%), fever (21%), thrombocytopenia (18%), and anorexia (8%). Only 8% of Thai CLL patients were asymptomatic at presentation. The majority of patients were categorized as stages III and IV with the median survival of 20 months and 8 months, respectively. Infection was the most common cause of death, particularly in the elderly patients who had comorbid illnesses. Twenty-two percent of the patients had associated autoimmune disorders. The unfavorable prognostic factors observed were older age (> 70 years), weight loss and hepatosplenomegaly. We concluded that the age and gender of Thai CLL patients were similar to those of the Western countries but our patients came to medical attention at a later and more advanced stage. Prospective studies at a multi-center level in Thailand should be pursued to investigate further the genetic and epidemiologic nature of Thai CLL patients.
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PMID:Clinical presentation and outcome of Thai patients with chronic lymphocytic leukemia: retrospective analysis of 184 cases. 1657 39

Infection commonly triggers nonspecific psychological and behavioral changes including fatigue and malaise, anhedonia, inability to concentrate, and disturbed sleep that collectively are termed "sickness behaviors". Converging evidence from several lines of research implicate the activities of proinflammatory cytokines as a cause of sickness behaviors. Here we elaborate upon the findings of previous research by examining whether infection-associated elevations in local proinflammatory cytokines are associated with increased negative mood and decreased positive mood. One hundred and eighty-nine healthy adults were experimentally exposed to rhinovirus or influenza virus during a 6-day period of quarantine. Infection, objective signs of illness, nasal IL-1beta, IL-6, and TNF-alpha, and self-reported affect were assessed at baseline and on each of the five post-challenge quarantine days. In the 153 persons who became infected following exposure to the challenge virus, daily production of IL-6, but not IL-1beta or TNF-alpha, was associated with reduced concurrent daily positive affect. One-day lagged analyses showed that daily production of all three cytokines was related to lower positive affect on the next day. All lagged associations were independent of previous-day positive affect and objective signs of illness (mucus production, mucociliary clearance function). There were no associations between cytokines and negative affect. Findings support a causal association between pathogen-induced local cytokine production and changes in positive affect over a 24-h timeline.
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PMID:Infection-induced proinflammatory cytokines are associated with decreases in positive affect, but not increases in negative affect. 1705 18


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