Prophylaxis against Pneumocystis carinii pneumonia among children with perinatally acquired human immunodeficiency virus infection in the United States. Pneumocystis carinii Pneumonia Prophylaxis Evaluation Working Group

BACKGROUND

Pneumocystis carinii pneumonia (PCP) remains a common and often fatal opportunistic infection among children infected with the human immunodeficiency virus (HIV). HIV-infected infants between three and six months of age are particularly vulnerable. Current guidelines recommend prophylaxis in children from birth to 11 months old who have CD4+ counts below 1500 cells per cubic millimeter.

METHODS

We used national surveillance data to estimate the annual incidence of PCP among children less than one year old. We reviewed the medical records of 300 children given a diagnosis of PCP between January 1991 and June 1993 to determine why treatment according to the 1991 guidelines for prophylaxis against PCP either was not given or failed to prevent the disease.

RESULTS

In our study the incidence of PCP in the first year of life among infants born to HIV-infected mothers changed little between 1989 and 1992. Among 7080 children born to HIV-infected mothers in 1992, PCP developed in 2.4 percent. Of 300 children with PCP diagnosed from January 1991 through June 1993, 199 (66 percent) had never received prophylaxis, and for 118 of those children (59 percent) exposure to HIV was first identified 30 days or less before the diagnosis of PCP. Among 129 children less than one year old, the CD4+ count declined by an estimated 967 cells per cubic millimeter (95 percent confidence interval, 724 to 1210 cells per cubic millimeter) during the three months before the diagnosis of PCP. Among infants in whom CD4+ counts were determined within one month of the diagnosis of PCP, 18 percent (20 of 113) had at least 1500 cells per cubic millimeter, a level higher than the currently recommended threshold for prophylaxis.

CONCLUSIONS

In the United States the incidence of PCP among HIV-infected infants has not declined. If this infection is to be prevented, infants exposed to HIV must be identified earlier, and prophylaxis must be offered to more children than the guidelines currently recommend.

HIV prevalence and risk factors in university students

OBJECTIVE

To estimate HIV prevalence and risks in university students.

DESIGN

Anonymous self-completion questionnaire and HIV survey with saliva samples.

SETTING

University students at matriculation.

PARTICIPANTS

All first and third year undergraduates and newly registering postgraduates at the University of Edinburgh, Scotland.

MAIN OUTCOME MEASURES

HIV prevalence, sexual behaviour, condom use, drug use.

RESULTS

The questionnaire responses were used to classify the 4665 respondents into four groups, ordered by risk of HIV positivity, and a sample of 2041 was selected for testing. All of the top two risk groups were tested (217 and 758 tests, respectively) as well as a random sample of the others. Five positive HIV-antibody tests were detected, all from the highest risk group. This gives an estimated rate of 1.2 per 1000 (95% confidence interval, 0.4-2.9) for all respondents. Only one of the five HIV-positives had been tested for HIV. The factors associated with HIV positivity were residence in Africa, intravenous drug use and male homosexuality. Overall, 74% of respondents reported ever having had sexual intercourse and this rate was the same for men and women. Reported intravenous drug use was very low: 0.5% for men and 0.1% for women. Condom use was more common for partners of short acquaintance, but unrelated to the number of sexual partners in the last year.

CONCLUSIONS

There was no evidence of the spread of HIV infection beyond known high-risk groups in this population. This may be a result of relatively low levels of HIV risk-taking behaviour in the majority of respondents.

Challenging conventional roles in palliative care

In October 1991, North Humberside was offered its own in-patient palliative care service. This was a natural development of the existing Macmillan Nurse Service and the hospice day centre. This paper discusses how the role of the nurse practitioner has developed.

Workforce planning methods will cause staff shortages

The current method used to decide how many nurses need to be trained to meet demand is not working and must be changed if shortfalls in the number of qualified nurses are to be avoided, a major report has claimed.

ANS leader for Europe group

The Association of Nursing Students took over the presidency of the European Nursing Students Group (ENSG) at its annual meeting in the autumn.

Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group

BACKGROUND AND METHODS

Maternal-infant transmission is the primary means by which young children become infected with human immunodeficiency virus type 1 (HIV). We conducted a randomized, double-blind, placebo-controlled trial of the efficacy and safety of zidovudine in reducing the risk of maternal-infant HIV transmission. HIV-infected pregnant women (14 to 34 weeks' gestation) with CD4+ T-lymphocyte counts above 200 cells per cubic millimeter who had not received antiretroviral therapy during the current pregnancy were enrolled. The zidovudine regimen included antepartum zidovudine (100 mg orally five times daily), intrapartum zidovudine (2 mg per kilogram of body weight given intravenously over one hour, then 1 mg per kilogram per hour until delivery), and zidovudine for the newborn (2 mg per kilogram orally every six hours for six weeks). Infants with at least one positive HIV culture of peripheral-blood mononuclear cells were classified as HIV-infected.

RESULTS

From April 1991 through December 20, 1993, the cutoff date for the first interim analysis of efficacy, 477 pregnant women were enrolled; during the study period, 409 gave birth to 415 live-born infants. HIV-infection status was known for 363 births (180 in the zidovudine group and 183 in the placebo group). Thirteen infants in the zidovudine group and 40 in the placebo group were HIV-infected. The proportions infected at 18 months, as estimated by the Kaplan-Meier method, were 8.3 percent (95 percent confidence interval, 3.9 to 12.8 percent) in the zidovudine group and 25.5 percent (95 percent confidence interval, 18.4 to 32.5 percent) in the placebo group. This corresponds to a 67.5 percent (95 percent confidence interval, 40.7 to 82.1 percent) relative reduction in the risk of HIV transmission (Z = 4.03, P = 0.00006). Minimal short-term toxic effects were observed. The level of hemoglobin at birth in the infants in the zidovudine group was significantly lower than that in the infants in the placebo group. By 12 weeks of age, hemoglobin values in the two groups were similar.

CONCLUSIONS

In pregnant women with mildly symptomatic HIV disease and no prior treatment with antiretroviral drugs during the pregnancy, a regimen consisting of zidovudine given ante partum and intra partum to the mother and to the newborn for six weeks reduced the risk of maternal-infant HIV transmission by approximately two thirds.

Staining of amyloid precursor protein to study axonal damage in mild head injury

The most common definition of cerebral concussion is that of a transient loss of neurological function without macroscopic or microscopic abnormality in the brain. However, some patients have persistent symptoms and subtle neuropsychological deficits, particularly affecting memory. We have studied five patients aged 59-89 years who sustained mild concussive head injury and died of other causes (2-99 days post-injury). Immunostaining with an antibody to amyloid precursor protein, a marker of fast axonal transport, showed multifocal axonal injury in all five. All had axonal damage in the fornices, which are important in memory function.

Nurses must face the reality of decisions over rationing

Nurses should keep up the fight for more resources but must recognise they will always face crucial rationing decisions, the recent annual conference of the RCN Cancer Nursing Society was told.

Nurse prescribing should not be limited to England

The UKCC is to write to the health departments in Scotland, Wales and Northern Ireland to ask what ministers are doing to implement nurse prescribing in their countries.

RCN fights plans for single-union deal

The Royal College of Nursing is fighting plans by a Glasgow trust to negotiate pay and conditions with only one union for each category of staff.

Nurse productivity now better than ever

Nurses' productivity is rising fast, the RCN claimed this week in a briefing document for NHS managers. It comes as the Government prepares to publish hospital league tables, described by critics as 'crude', and concerned only with numbers while ignoring standards.

A prospective, double-blind trial of electrical capacitive coupling in the treatment of non-union of long bones

Twenty-three patients who had an established non-union of a long bone were entered into a prospective, double-blind trial in which electrical capacitive coupling was used for treatment. Twenty-one patients completed the study: ten who were actively managed and eleven who were managed with a placebo unit. The non-union healed in six of the ten patients who had been managed actively but in none of the patients who had been managed with the placebo unit. This difference in the rates of healing between the actively managed and the placebo groups is highly significant (p = 0.004).

Brain injury patterns in fatally injured pedestrians

To study the relationship between the severity of impact to the head and the severity and distribution of injury to the brain in fatally injured pedestrians, events in vehicle-pedestrian collisions were reconstructed to determine the peak linear and angular acceleration sustained by the pedestrians' heads. The nature and distribution of injuries to the brain were determined by neuropathologic examination of coronal sections of the brain. Study of 13 cases with occipital impacts and 18 with lateral impacts showed that the brain appeared to be more susceptible to injury from lateral impacts. The frontal and temporal regions appeared to be more susceptible to injury at low accelerations in occipital impacts, providing an explanation for "coup" and "contrecoup" injuries. For occipital impacts, a positive relationship was found between linear acceleration and the extent of injury to the brain, suggesting that there was a threshold for observable and concussive brain injury at about 1500 m/s2 peak linear acceleration. These findings are important for the development of measures for preventing brain injuries.