Surveillance for AIDS-defining opportunistic illnesses, 1992-1997

PROBLEM/CONDITION

Acquired immunodeficiency syndrome (AIDS)-defining opportunistic illnesses (OIs) are the major cause of morbidity and mortality among persons infected with human immunodeficiency virus (HIV). As a result of new treatments that reduce mortality for persons with AIDS, the number of persons living with AIDS is increasing, and the incidence of AIDS is decreasing. In 1997, an estimated 271,245 persons were living with AIDS in the United States and thus were at high risk for OIs. In 1997, an estimated 21,909 HIV-infected persons died with AIDS, nearly all as a result of OIs.

REPORTING PERIOD COVERED

Aggregate data and trends for 1992-1997 were examined to determine a) the frequencies at which OIs occurred first; b) the incidence of OIs; c) the percentage of persons among those who have died who had had a given OI during their course of AIDS, and d) the frequency of prescriptions for antiretroviral therapy and prophylaxis for Pneumocystis carinii pneumonia (PCP) and for Mycobacterium avium complex disease (MAC).

DESCRIPTION OF SYSTEM

Data were analyzed from the Adult/Adolescent Spectrum of HIV Disease (ASD) sentinel surveillance project, a prospective medical record review of HIV-infected persons aged > or = 13 years conducted in 11 U.S. cities. ASD data were standardized to national AIDS surveillance data for 1992-1997 by age; race; sex; country of birth; year of AIDS diagnosis; HIV exposure mode; and for incidence calculations, by CD4+ T-lymphocyte distribution.

RESULTS

The incidence declined significantly for each of 15 of the 26 specific AIDS-defining OIs (p<0.05). PCP was the most common AIDS-defining OI to occur first (PCP was the first OI to occur for 36% of HIV-infected persons), the most common incident AIDS-defining OI (274 cases per 1000 person-years), and the most common AIDS-defining OI to have occurred during the course of AIDS (53% of persons who died with AIDS had PCP diagnosed at some time during their course of AIDS). Of persons with CD4+ T-lymphocyte counts <500 cells/microL, the number with prescriptions for triple combination therapy increased from zero in 1992 to 40% in 1997, and 80% of persons had a prescription for any antiretroviral therapy in 1997. Of persons with CD4+ T-lymphocyte counts <200 cells/microL, the percentage with prescriptions for PCP prophylaxis remained stable from 1992 through 1997 (range: 75% to 80%). Of persons with CD4+ T-lymphocyte counts <50 cells/microL, the percentage with prescriptions for MAC prophylaxis increased from 9% in 1992 to 44% in 1997.

INTERPRETATIONS

The incidences of many OIs are decreasing primarily because of advances in HIV-related therapy. However, OIs are still occurring, especially when patients access care late during the course of disease. Even after accessing care, persons may develop OIs because of lack of prescription for prophylaxis, antiretroviral drug resistance, or poor adherence to therapy. During 1992-1997, most patients in need of PCP prophylaxis received a prescription for it; however, even in 1997, most patients in need of MAC prophylaxis did not receive a prescription for it.

ACTIONS TAKEN

These surveillance data are used by persons involved with developing guidelines for preventing OIs to determine the importance of and trends in OIs and preventive therapy. CDC is developing population-based approaches for surveillance of HIV disease progression, OIs, and therapies with the goal of making these data available in more geographic areas to help assess public health and health-care programs.

Cervical screening among immigrant Vietnamese women seen in general practice: current rates, predictors and potential recruitment strategies

OBJECTIVE

To ascertain cervical screening rates among Vietnamese women attending Vietnamese-speaking general practitioners (GPs) in Sydney, their recall of opportunistic recruitment by these GPs and their preferences for strategies to encourage screening.

METHOD

Women born in Vietnam aged 18-69 years were recruited through the waiting room of their GP and completed questionnaires in either Vietnamese or Chinese before and after their consultation.

RESULTS

Of 355 women seen during the survey period, 170 were ineligible. Of those eligible, 118 women (64% response rate) completed waiting room questionnaires. Of 86 women 'at risk', 56 (65%) reported having a cervical smear within two years or due on that day; 26 (86%) of those 30 women overdue for screening reported visiting a GP at least twice in the past six months. After adjustment for age and education, women who were more acculturated or had resided in Australia for the most years remained significantly more likely to be screened (p = 0.027 and p = 0.037 respectively). In the follow-up questionnaire, returned by 49 women (52%) who agreed to receive it, recall of opportunistic advice from the GP was low. Female GPs, free screening and more information in Vietnamese were the three most popular recruitment strategies.

CONCLUSION

Study confirms low participation rates in cervical screening by Vietnamese women using self-report. Recent immigrants and the least acculturated are least likely to be screened.

IMPLICATIONS

A community-based strategy involving Vietnamese-speaking GPs shows promise, inviting behavioural evaluation.

Developmental surface dysgraphia: what is the underlying cognitive impairment?

The purpose of this study was to investigate the cognitive causes underlying spelling difficulties in a case of developmental surface dysgraphia, AW. Our results do not support a number of possibilities that could be the cause of AW's poor orthographic lexicon, including difficulties in phonological processing, phonological short-term memory, configurational visual memory, and lexical semantic memory. We have found instead that AW performs poorly in tasks that involve detection of the order of adjacent letters in a word or the order of adjacent units in strings of consonants or symbols. Finally, he performs poorly in tasks that involve reconstructing the order of a series of complex visual characters (Japanese and Hindi characters) especially when these are presented sequentially. We advance the hypothesis that AW's poor spelling and good reading skills stem from an underlying pattern of cognitive abilities where a very good visual configurational memory is coupled with a poor ability to encode serial order. This may have resulted in a holistic word-based reading strategy, which, together with the original problem of encoding order, may have had detrimental effects for the acquisition of spelling.

Obtaining resources for evidence-based public health initiatives at the local level: insights from the Central Sydney Tobacco Control Plan

OBJECTIVE

In response to inquiries regarding the processes of developing a Tobacco Control Plan (TCP) for the Central Sydney Area Health Service (which in 1997 allocated dedicated funding of $ 800,000 over 2 1/2 years to implement the plan), this article describes the strengths and weaknesses of the TCP and outlines the process which contributed to its funding.

CONCLUSIONS

Consistent with national and state priorities, the TCP recommended strategies based on best available evidence in the four action areas: reducing sales of cigarettes to minors, marketing, passive smoking and smoking cessation. Funding of this amount for a single public health issue at a local level represents a unique achievement in the application of an evidence-based approach to population health.

IMPLICATIONS

Key elements of our advocacy methods included the involvement of all key primary health care and clinical stakeholders; comprehensive background research to identify evidence-based strategies; careful attention to budget options; strategic lobbying of senior staff and decision makers; the proposal for a multidisciplinary management structure for the TCP and specifications for funding allocation and evaluation. Early achievements and other reflections are discussed.

Hepatic lesion detection: comparison of MR imaging after the administration of superparamagnetic iron oxide with dual-phase CT by using alternative-free response receiver operating characteristic analysis

PURPOSE

To compare the performance of magnetic resonance (MR) imaging after the administration of superparamagnetic iron oxide (SPIO) and dual-phase computed tomography (CT) in the depiction of liver metastases.

MATERIALS AND METHODS

Fifty-one hepatic resection candidates with known colorectal metastases were examined. MR imaging comprised fast spin-echo (SE) T2-weighted imaging, T1-weighted gradient-echo (GRE) fast low-angle shot imaging before SPIO enhancement, dual-echo SE imaging, T2-weighted fast low-angle shot imaging, and T1-weighted GRE imaging after SPIO enhancement. CT was performed with 8-mm collimation and 1:1 pitch; imaging commenced 20 seconds and 65-70 seconds after injection of 150 mL of contrast medium. All images were reviewed independently by four blinded observers. The alternative-free response receiver operating characteristic (ROC) method was used to analyze the results, which were correlated with findings from surgery, intraoperative ultrasonography, and histopathologic studies in 31 patients and with consensus review together with all other imaging and clinical follow-up in 20 patients. Sensitivities were also calculated.

RESULTS

The mean sensitivity of MR was significantly higher than that of CT (p < .02): 79.8% for MR and 75.3% for CT for all lesions, and 80.6% for MR and 73.5% for CT for malignant lesions. The mean areas under the alternative-free response ROC curves were 0.83 for MR and 0.78 for CT (difference not significant).

CONCLUSION

SPIO-enhanced MR imaging was more sensitive than dual-phase CT in the depiction of colorectal metastases.

Role of maintenance treatment in opioid dependence

Methadone maintenance treatment (MMT) involves the daily administration of the oral opioid agonist methadone as a treatment for opioid dependence-a persistent disorder with a substantial risk of premature death. MMT improves health and reduces illicit heroin use, infectious-disease transmission, and overdose death. However, its effectiveness is compromised if low maintenance doses of methadone (<60 mg) are used and patients are pressured to become prematurely abstinent from methadone. Pregnancy and psychiatric comorbidity are not contraindications for MMT. As an alternative to MMT, other oral opioid agents (eg, naltrexone, buprenorphine) may increase patient choice and avoid some of the more unpleasant aspects of MMT. The public-health challenge for the future is to develop and continue to deliver safe and effective forms of opioid maintenance treatment to as many opioid-dependent individuals as can benefit from them.

Do the beliefs of Australian general practitioners about the effectiveness of cancer screening accord with the evidence?

A national random sample of 855 Australian general practitioners was surveyed about their belief in the effectiveness of cancer screening tests in reducing premature mortality. Responses were then compared with scientific evidence of effectiveness for each test. 92% of respondents believed mammography to be effective compared with only 38% for faecal occult blood testing, despite comparable evidence of effectiveness from randomised controlled trials. Seven tests outranked their belief in faecal occult blood testing, despite weaker evidence. Further efforts are required to align general practitioners' beliefs better with the evidence.

Local implementation of national guidelines on lower urinary tract symptoms: what do general practitioners in Sydney, Australia suggest will work?

OBJECTIVES

Systematic reviews demonstrate that local initiatives are vital to implement nationally developed clinical practice guidelines. Evidence-based guidelines on the management of lower urinary tract symptoms in men were launched by the National Health and Medical Research Council in Sydney in April 1997. A study was conducted through interviews to establish patterns of care in the catchment area before the guidelines were implemented and general practitioners were surveyed in order to ascertain the most useful strategies for local implementation.

DESIGN

A four-page questionnaire asked respondents to rate nine items about guideline dissemination; six items relating to the marketing of the guidelines and 15 implementation strategics: conventional educational activities (six); innovative educational strategies (four); quality improvement approaches (two) and patient-based approaches (three).

SETTING

Sydney, Australia.

STUDY PARTICIPANTS

Eighty-three randomly selected general practitioners (50 males; 33 females).

RESULTS

Eighty-three out of 108 surveys were returned (77%). Respondents placed high value upon endorsement by eminent individuals and organizations other than the organization developing the guidelines; this was likely to gain their initial attention. One hundred per cent of respondents would be encouraged to use the guidelines if they were promoted as improving quality of care. Implementation strategies preferred by respondents included small group continuing education with a urologist and a general practitioner as a facilitator, lectures and patient education materials. Internet access, interactive computer systems, academic detailing' and distance education modules were of least interest.

CONCLUSIONS

Our method is feasible as a first step in planning local dissemination and implementation for national guidelines. While useful in identifying preferred strategies, its longer-term predictive validity for improving patient outcomes through better guideline implementation needs to be established.

Outcome after surgery for perianal fistula: predictive value of MR imaging

OBJECTIVE

The purpose of this study was to determine if MR findings are predictive of long-term outcome in a cohort of patients whose initial surgery was performed without access to the findings of MR imaging.

SUBJECTS AND METHODS

Forty patients with surgically proven perianal fistulas underwent preoperative dynamic contrast-enhanced MR imaging. The MR and surgical findings were independently recorded on an identical anatomic form. Three patients were subsequently lost to follow-up. The outcome for the remaining 37 patients was determined from surgical review, case notes, and questionnaires. Minimum follow-up period was 14 months (range, 14-39 months). Outcome was determined by one observer who was unaware of the initial MR grading and had not been present during surgery. Outcome was considered unsatisfactory if further surgery was required.

RESULTS

MR imaging was better than surgical exploration in predicting outcome (for MR imaging: positive predictive value, 73%; negative predictive value, 87%; sensitivity, 89%; and specificity, 68%; for surgical exploration: positive predictive value, 57%; negative predictive value, 64%; sensitivity, 73%; and specificity, 47%). MR classification of fistulas was significantly associated with outcome (p = .0004), and surgical classification was not significantly associated with outcome (p = .22, chi-square test). Also MR grades differed significantly for patients with satisfactory and unsatisfactory outcomes (p < .001, Mann-Whitney U test).

CONCLUSION

MR imaging is valuable in the management of patients with perianal fistulas. MR imaging accurately reveals surgical anatomy and can be used to make better predictions regarding patient outcome than surgical findings.

Cardiovascular risk factors among Arabic-speaking patients attending Arabic-speaking general practitioners in Sydney, Australia: opportunities for intervention

BACKGROUND

Australia has a high rate of cardiovascular disease mortality and also a significant proportion of migrants. Little is known about the morbidity experience or cardiovascular risk factors among the larger migrant groups, and this is especially true of the Arabic-speaking population.

OBJECTIVES

The objectives of the study were to identify the health profile of Arabic-speaking people in Sydney, Australia, to explore the relationship between level of acculturation and health indicators and to identify the morbidity profile of patients presenting to Arabic-speaking general practitioners (GPs).

DESIGN

Adult Arabic-speaking patients aged 18-70 years attending 20 Arabic-speaking GPs in Canterbury, Sydney, during the 2-week study period were asked to complete a self-administered questionnaire in Arabic or English while waiting to see the GP. Data on cardiovascular risk factors, level of acculturation and reasons for seeing the GP were collected.

RESULTS

Data were collected from 851 patients (62% response rate). Almost three-quarters (73%) of males and 36% of females were considered overweight or obese (body mass index > 25). Of concern, 37% of males and 28% of females were smokers. Females were significantly less likely to have been tested for diabetes (p < .05) or raised blood pressure (p < 0.05) compared with females in NSW. Respondents consumed less bread per day and more fruits than in NSW overall. Respiratory complaints (flu and colds) were the most frequently reported reasons for patient encounters. Except for the youngest age group, males gave more reasons for encounters than females.

CONCLUSIONS

Consecutive sampling of ethnic patients attending a GP who speaks their language holds promise as a method of needs assessment with migrant populations. Further, our results suggest that smoking and weight reduction programs are priorities in the Arabic-speaking community. These risk factors are ideal for intervention by GPs speaking the same language.

Targeted disruption of the acid alpha-glucosidase gene in mice causes an illness with critical features of both infantile and adult human glycogen storage disease type II

We have used gene targeting to create a mouse model of glycogen storage disease type II, a disease in which distinct clinical phenotypes present at different ages. As in the severe human infantile disease (Pompe Syndrome), mice homozygous for disruption of the acid alpha-glucosidase gene (6(neo)/6(neo)) lack enzyme activity and begin to accumulate glycogen in cardiac and skeletal muscle lysosomes by 3 weeks of age, with a progressive increase thereafter. By 3.5 weeks of age, these mice have markedly reduced mobility and strength. They grow normally, however, reach adulthood, remain fertile, and, as in the human adult disease, older mice accumulate glycogen in the diaphragm. By 8-9 months of age animals develop obvious muscle wasting and a weak, waddling gait. This model, therefore, recapitulates critical features of both the infantile and the adult forms of the disease at a pace suitable for the evaluation of enzyme or gene replacement. In contrast, in a second model, mutant mice with deletion of exon 6 (Delta6/Delta6), like the recently published acid alpha-glucosidase knockout with disruption of exon 13 (Bijvoet, A. G., van de Kamp, E. H., Kroos, M., Ding, J. H., Yang, B. Z., Visser, P., Bakker, C. E., Verbeet, M. P., Oostra, B. A., Reuser, A. J. J., and van der Ploeg, A. T. (1998) Hum. Mol. Genet. 7, 53-62), have unimpaired strength and mobility (up to 6.5 months of age) despite indistinguishable biochemical and pathological changes. The genetic background of the mouse strains appears to contribute to the differences among the three models.

Impact in general practice of the policies of the organised approach to preventing cancer of the cervix

This cross-sectional survey of cancer screening in May 1996 used a national random sample of a specified group of general practitioners (GPs). The survey included items to assess the impact of the Organised Approach to the Prevention of Cervical Cancer (OAPCC). Of the 1,271 GPs who satisfied the eligibility criteria, 855 (67%) returned a completed questionnaire. Fifty-two per cent indicated they would be 'highly' likely to introduce a discussion about cervical smears to a 58-year-old woman who was in good health and had come for a non-gynaecological consultation. Female sex, RACGP affiliation, practising in a metropolitan area and awareness of the OAPCC booklet were independent predictors of an opportunistic orientation. By contrast, 91% indicated that they would be 'highly' likely to include a Pap smear in a general health checkup. Thirty-eight per cent reported that they had found the booklet about the 1991 screening policy 'very' useful, while 38% found the NHMRC guidelines for the management of women with screen detected abnormalities 'very' useful. Around one-fifth of the GPs were not aware of these documents. Overall, 19% still recommended annual or more frequent screening. GPs from NSW and Queensland were less likely to support biennial screening than GPs from other states. Overall, 26% of GPs did not indicate that they would refer a woman who had tested positive for any grade of CIN for colposcopic assessment. Female GPs were more likely to refer women with CIN for colposcopic assessment while older doctors were less likely to do so.

Labour-saving strategies to maintain survey response rates: a randomised trial

To evaluate response-aiding strategies feasible in large surveys, we randomly allocated general practitioners (GPs) to one of four intervention groups: Group 1 received 'exhaustive' telephone prompts by a medical peer in advance of a questionnaire; Group 2, inclusion of an embossed pen with the questionnaire; Group 3, an advance letter prompt; and Group 4, a 'single attempt' advance telephone prompt by a non-medical research assistant. Follow-up procedures were identical. Response rates by group were not significantly different overall (chi 2 = 4.59, df = 3, p = 0.20) although advance prompts by a medical peer were significantly more effective than other strategies for male GPs. The difference in overall response rates between males (63%) and females (74%) was significant (chi 2 = 15.40, df = 1, p < 0.01). No other response bias was evident. Our demonstration of a significant interaction between respondent sex and response-aiding strategy invites further research.

Australian general practitioners' views and use of tests to detect early prostate cancer

To describe general practitioners' current beliefs, knowledge and self-reported practices in prostate cancer screening, we conducted a national survey of 1,271 general practitioners, obtaining 855 completed questionnaires (67% response rate). Available tests for prostate cancer screening, namely DRE and PSA alone and in combination, were indicated to be effective by 49%, 43% and 68% of respondents respectively, with older GPs significantly more likely to hold these views. The effect of guidelines was mixed. Less than 8% of respondents indicated they did not recommend screening. Although the majority of GPs were unlikely to adopt an opportunistic approach to prostate cancer screening, 63%, 57% and 46% indicated they would recommend DRE, PSA or both respectively during a dedicated health check up. Awareness of relevant guidelines was low, with nearly half of respondents unable to recall publications from the RACGP or ACS. Counter-intuitively, awareness of ACS guidelines for prostate cancer screening (which advise against screening) was significantly associated with the converse behaviour. Findings from this first national study behove proactive and highly targeted dissemination in general practice of the AHTAC policy announced by the Commonwealth Health Minister in August 1996.

A novel protein complex that interacts with the vitamin D3 receptor in a ligand-dependent manner and enhances VDR transactivation in a cell-free system

Nuclear receptors transduce hormonal signals by binding directly to DNA target sites in promoters and modulating the transcription of linked genes. Receptor-mediated transactivation appears to be potentiated in response to ligand by a number of coactivators that may provide key interactions with components of the transcription preinitiation complex and/or alter chromatin structure. Here, we use the vitamin D3 receptor ligand-binding domain (VDR LBD) as an affinity matrix to identify components of a transcriptionally active nuclear extract that interact with VDR in response to ligand. We describe the purification of a complex of at least 10 VDR interacting proteins (DRIPs) ranging from 65 to 250 kD that associate with the receptor in a strictly 1,25-dihydroxyvitamin D3-dependent manner. These proteins also appear to interact with other, but not all, nuclear receptors, such as the thyroid hormone receptor. The DRIPs are distinct from known nuclear receptor coactivators, although like these coactivators, their interaction also requires the AF-2 transactivation motif of VDR. In addition, the DRIP complex contains histone acetyltransferase activity, indicating that at least one or more of the DRIPs may function at the level of nucleosomal modification. However, we show that the DRIPs selectively enhance the transcriptional activity of VDR on a naked DNA template utilizing a cell-free, ligand-dependent transcription assay. Moreover, this activity can be specifically depleted from the extract by liganded, but not unliganded, VDR-LBD. Overexpression of DRIP100 in vivo resulted in a strong squelching of VDR transactivation, suggesting the sequestration of other limiting factors, including components of the DRIP complex. These results demonstrate the existence of a new complex of novel functional nuclear receptor coactivators.

Rational engineering of the TOL meta-cleavage pathway

The meta-cleavage pathway of Pseudomonas putida mt-2 was simulated using a biochemical systems simulation developed by Regan (1996). A non-competitive inhibition term for catechol-2,3-dioxygenase (C23O) by 2-OH-pent-2,4-dienoate (Ki = 150 μM) was incorporated into the model. The simulation predicted steady state accumulation levels in the μM range for metabolites pre-meta-cleavage, and in the mM range for metabolites post-meta-cleavage. The logarithmic gains L[V-i, Xj] and L[X-i, Xj] clearly indicated that the pathway was most sensitive to the concentration of the starting substrate, benzoate, and the first enzyme of the pathway, toluate-1, 2-dioxygenase (TO). The simulation was validated experimentally; it was found that the amplification of TO increased the steady state flux from 0.024 to 0.091 (mmol/g cell dwt)/h. This resulted in an increased accumulation of a number of the pathway metabolites (intra- and extracellularly), especially cis-diol, 4-OH-2-oxovalerate, and 4-oxalocrotonate. Metabolic control analysis indicated that C23O was, in fact, the major controling enzymic step of the pathway with a scaled control coefficient of 0.83. The amplification of TO resulted in a shift of some of the control away from C23O. Catechol-2,3-dioxygenase, however, remained as the major controling element of the pathway. Copyright 1998 John Wiley & Sons, Inc.

Comparison of dyspnea ratings during submaximal constant work exercise with incremental testing

PURPOSE

The purpose of this study was to determine whether dyspnea ratings would be similar during submaximal (as used for training) and incremental (as used in testing) exercise at specific intensities in patients with chronic obstructive pulmonary disease (COPD).

METHODS

We studied 20 patients with COPD. Age was 66 +/- 9 yr (mean +/- SD); FEV1 was 43 +/- 14% pred. At Visit 1 patients provided dyspnea ratings (0 to 10 scale) each minute during incremental exercise on the cycle ergometer. At Visit 2 patients rated dyspnea during production of submaximal exercise for 10 min at two intensities.

RESULTS

Peak oxygen consumption (VO2) was 13.9 +/- 3.2 mL.kg-1.min-1. At visit 2 VO2 was stable, but dyspnea ratings increased slightly. Dyspnea ratings (2.0 +/- 1.2) during submaximal exercise were higher than during incremental exercise (1.1 +/- 0.7) at 55 +/- 8% of peak VO2 (P = 0.02) but were similar (4.3 +/- 1.5 vs 3.9 +/- 1.5) at 77 +/- 8% of peak VO2 (P = 0.40).

CONCLUSIONS

In patients with COPD, dyspnea ratings were similar during steady state compared with equivalent levels of incremental exercise at a "high" intensity, but were slightly higher at the "low" exercise intensity. These data support the potential use of dyspnea ratings obtained during incremental exercise as a target for exercise training in patients with respiratory disease.