Haematological support during peg-interferon therapy for HCV-infected haemophiliacs improves virological outcomes

Hepatitis C virus-infected haemophiliacs are traditionally under represented in international treatment studies thus data assessing response to pegylated-interferon (peg-IFN) and ribavirin (RBV) in HCV mono-infected or HCV/HIV co-infected haemophiliacs are few. Since 2001, 37 haemophiliac patients have received peg-IFN and RBV according to centre-based investigator initiated protocols. Primary end points were: early virological response (EVR); end of treatment response (EOTR) and sustained virological response (SVR). An intention-to-treat analysis was used. Secondary end points were adverse events, haemopoietic stem cell growth factor use, therapy discontinuations and dose reductions. Hepatitis C virus mono-infection group (Mono-I) numbered 20 (60% genotype 1). HCV/HIV co-infected group (Co-I) numbered 17 (59% genotype 1/4). Primary end points were: EVR 76%, EOTR 70% and SVR 43%. Comparison of Mono-I to Co-I demonstrated: EVR rates of 70% and 82%, respectively; EOTR rates of 65% and 76%, respectively, and SVR rates of 35% and 53%, respectively. SVR rates genotype 1/4 group - 17% (Mono-I) vs. 30% (Co-I); SVR rates genotype 2/3 group - 63% (Mono-I) vs. 86% (Co-I). Therapy discontinuations: six of 20 (30%) Mono-I vs. three of 17 (18%) Co-I. Dose reductions: two of 20 (10%) Mono-I vs. zero of 17 Co-I. Haematological support factor use: one of 20 (5%) Mono-I vs. four of 17 (23.5%) Co-I. Virological outcomes to peg-IFN and RBV in HCV-infected haemophiliacs are comparable to published data relating to other HCV-infected cohorts. Good virological outcomes can be achieved in HIV co-infected haemophiliacs particularly when growth factors are used to facilitate full dosing of peg-IFN and RBV.

Adjuvant trastuzumab (T) in early stage breast cancer (EBC): Is cardiac dysfunction (CD) clinically significant?

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Background: T was funded for women with EBC in Ontario in Aug 05. Clinicians remain concerned about the potential cardiotoxicity of T in women with EBC. The purpose of this retrospective study is to evaluate CD in women with EBC prescribed adjuvant T therapy. Methods: Women with HER2-overexpressing EBC who were initiated on T and chemotherapy (CT) at TOHRCC between Aug 05 and Nov 06 were included in this analysis. A retrospective chart review collected: demographics, CT regimen, T treatment (dose delays, termination of T), CD (defined by the New York Heart Association functional classification, 2002), and management. Results: Outcomes reflect the preliminary results of 108 patients (pts) initiated on adjuvant T therapy. Median age was 52 years (range 30–79). 107 pts (95%) received T and CT; 1 pt received T alone. Pts received an average of 6 cycles of CT (range 1–12), including anthracycline (A; 99%) (A alone 55%; A-taxane 44%) and non-A (1%) regimens. 18 pts (28%) were treated with concurrent T and taxol. Therapy with T has been completed (median 46.7 weeks) in 28 pts (26%) while 72 pts (67%) remain on T. 85% of pts underwent at least 3 MUGA scans during T treatment. CD was observed in 18 pts (17%): congestive heart failure (2 pts), decrease in left ventricular ejection fraction (LVEF) of =10% to less than 55% (14 pts) or decrease in LVEF >20% (2pts). Of 18 pts with CD, 7 underwent a treatment delay (median 8 weeks) 3 permanently stopped T (median 45 weeks) and 8 pts continued T. 31 pts experiencing any decrease in LVEF were managed successfully through: delay, (16 pts), referral to a cardiologist (14 pts) and medical treatment with: ACE-inhibitors (5 pts), beta blockers (1 pt), or combination (2 pts). Discussion: The results of this first analysis indicate that outside of a clinical trial setting, the majority of women receive adjuvant T according to treatment guidelines, do not experience significant CD and are able to complete therapy uninterrupted. The long term consequences of CD in these pts are unknown.

No significant financial relationships to disclose.

Purpura fulminans associated with Lactobacillus paracasei liver abscess

Purpura fulminans is a rare but devastating haemorrhagic condition often associated with sepsis. Many different organisms have been implicated in the aetiology of purpura fulminans, most commonly Neisseria meningitidis and Streptococcus pneumoniae. We report a case of purpura fulminans associated with Lactobacillus paracasei liver abscess. Purpura fulminans has not previously been associated with this organism and specific bacteriological testing was used to exclude the presence of other species.

Maternal hepatotoxicity with nevirapine as part of combination antiretroviral therapy in pregnancy

OBJECTIVES

To describe the maternal tolerability of nevirapine as part of combination antiretroviral therapy in pregnancy at three HIV centres in Dublin, Ireland and to determine risk factors for development of significant hepatotoxicity.

METHODS

A retrospective study was carried out of all women prescribed nevirapine as part of combination antiretroviral therapy in pregnancy at three HIV centres in Dublin, Ireland (October 2000 to February 2003). Toxicities experienced were graded according to the Division of AIDS toxicity guidelines for adults. Statistical analysis was performed to determine whether there were differences between those that did and those that did not experience significant hepatotoxicity.

RESULTS

A total of 123 women initiated nevirapine as part of combination antiretroviral therapy in the study period. Eight women developed significant hepatotoxicity, including two women who died from fulminant hepatitis. Women who experienced more severe hepatotoxicity had higher pretreatment CD4 counts (P=0.01).

CONCLUSIONS

In this cohort, women who experienced more severe hepatotoxicity had higher pretreatment CD4 counts, lending additional weight to the need for caution in using nevirapine as part of combination antiretroviral therapy in women not requiring antiretroviral therapy for their own health.

An analysis of adjuvant temozolomide plus radiotherapy vs radiotherapy alone in a single academic institution

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Background: The NCIC CE.3/EORTC 22981/26981 was open during the time period of August 2000 to March 2002. When the study closed, there existed a gap in care that did not address the ongoing management of patients (pts) with glioblastoma multiforme (GBM) that had been surgically excised. As a result of this gap, it was decided that the adjuvant use of temozolomide (TMZ) was to become the standard of care at our centre due to its lack of perceived toxicities and early evidence for its activity. Methods: An analysis was performed of all pts with GBM that were seen at the centre from 1998 to the summer of 2005. In total, 240 pts were identified across multiple medical and radiation oncologists. 75 pts were treated with radiotherapy (RAD) alone post surgery, 86 pts were treated with RAD + TMZ post surgery, 18 pts only had surgery and the remaining pts were unresectable. Average age was 59.7 years for pts treated only with RAD, and 54.6 years for those treated with TMZ + RAD (p = 0.028). 59% of pts treated with RAD were male, while 62% treated with RAD + TMZ were male. Median follow-up was 11.3 months for RAD and 15.7 months for TMZ + RAD (p = 0.0001816). Preliminary survival analysis demonstrates a 56% reduction in the risk of death for pts treated with TMZ + RAD when compared to RAD (log rank p = 9.6 × 10−6). Median survival was 12.7 months for pts treated with RAD and 27 months for pts treated with TMZ + RAD (see table ). A further analysis including recursive partitioning analysis (RPA) and duration of therapy post RAD will be attempted to confirm the similarities between the two groups. Conclusion: Adjuvant TMZ + RAD has increased overall survival by 14.3 months in our institution. Further analysis is necessary to determine the impact on duration of therapy of TMZ.

[Table: see text]

[Table: see text]

Role of individualization of hepatitis C virus (HCV) therapy duration in HIV/HCV-coinfected individuals*

OBJECTIVE

The aim of this study was to assess the efficacy, safety and tolerability of pegylated interferon and ribavirin in HIV/hepatitis C virus (HCV)-coinfected patients, prescribed for the same duration and at the same dosage as that used in HCV monoinfection studies.

DESIGN

It was an open-label, single-centre, prospective study.

METHODS

Forty-five patients coinfected with HIV and HCV with CD4 counts >200 cells/microL were treated with pegylated interferon-alpha2b 1.5 microg/kg/week and ribavirin 1000-1200 mg/day for 24-48 weeks depending on HCV genotype. Safety and tolerability were assessed weekly for the first month and monthly thereafter. Virological response was assessed at weeks 4, 12 and 24 and at the end of treatment and 12 and 24 weeks post completion of treatment. The primary endpoint was defined as undetectable HCV RNA at 24 weeks post completion of treatment [sustained virological response (SVR)].

RESULTS

The majority of patients were male and had been injecting drug users. Sixty per cent were on antiretroviral therapy. In an intention-to-treat analysis, 53% had an SVR (genotype 1, 19% and genotype 2/3, 75%). All patients who had undetectable HCV RNA at week 4 of HCV treatment [very early virological response (VEVR)] had a SVR. On multivariate analysis only HCV genotype predicted SVR. Adverse events occurred frequently.

CONCLUSIONS

These results indicate that 24 weeks of HCV treatment may be adequate for HIV-infected individuals coinfected with HCV genotype 2 or 3. VEVR can predict SVR in this group and may be used to guide the subgroup of genotype 2/3 individuals who will respond to 24 weeks of treatment.

Increasing resistance to ciprofloxacin among isolates of Neisseria gonorrhoea in Dublin

Neisseria gonorrhoeae cases are increasing in Ireland. Ciprofloxacin is often used as first line treatment for this infection in STI clinics. A retrospective study to analyze resistance in two Dublin clinics was undertaken. Cases were defined as patients from whom an isolate of N. gonorrhoea was recovered. All cases from two clinics between January 1997 and June 2003 were included. Antimicrobial resistance data was correlated with sex and sexuality. One thousand one hundred and eighty laboratory-confirmed cases were identified. Eighty seven percent were male. Sixty nine percent were MSM. Twenty seven percent of isolates demonstrated reduced susceptibility to penicillin and 6% to ciprofloxacin. Isolates with reduced susceptibility to ciprofloxacin increased year on year from 3.8% in 1997 to 15% in 2003. Prevalence of isolates of N. gonorrhoea with reduced susceptibility to ciprofloxacin has exceeded 10% in these clinics since 2002. In concordance with international guidelines, ceftriaxone became the treatment of choice for gonorrhoea in July 2003.

The role of oral microbial colonization in ventilator-associated pneumonia

The present article reviews the association between microbial colonization of the oral cavity and the lungs in critically ill patients that develop ventilator-associated pneumonia (VAP) in the intensive care unit (ICU) setting. The risk factors and microorganisms associated with VAP are presented. The role of oral colonization of VAP-associated pathogens (VAP-AP) in the development of VAP is examined. We explore the potential factors involved in oral colonization of VAP-AP, which are atypical bacteria for the oral cavity. Strategies for the prevention or moderation of oral colonization of VAP-AP have had limited success. We need a deeper understanding of the pathophysiology of VAP in order to reduce the morbidity, mortality, and cost from this common complication in ICU medicine and surgery.

The epidemiology of infectious syphilis in the Republic of Ireland

In response to the increasing numbers of syphilis cases reported among men having sex with men (MSM) in Dublin, an Outbreak Control Team (OCT) was set up in late 2000. The outbreak peaked in 2001 and had largely ceased by late 2003. An enhanced syphilis surveillance system was introduced to capture data from January 2000. Between January 2000 and December 2003, 547 cases of infectious syphilis were notified in Ireland (415 were MSM). Four per cent of cases were diagnosed with HIV and 15.4% of cases were diagnosed with at least one other STI (excluding HIV) within the previous 3 months. The mean number of contacts reported by male cases in the 3 months prior to diagnosis was 4 (range 0-8) for bisexual contacts and 6 for homosexual contacts (range 1-90). Thirty one per cent of MSM reported having had recent unprotected oral sex and 15.9% of MSM reported having had recent unprotected anal sex. Sixteen per cent of cases reported having had sex abroad in the three months prior to diagnosis. The results suggest that risky sexual behaviour contributed to the onward transmission of infection in Dublin. The outbreak in Dublin could be seen as part of a European-wide outbreak of syphilis. The rates of co-infection with HIV and syphilis in Ireland are comparable with rates reported from other centres. There is a need to improve surveillance systems in order to allow real time evaluation of interventions and ongoing monitoring of infection trends.

The epidemiology of infectious syphilis in the Republic of Ireland

In response to the increasing numbers of syphilis cases reported among men having sex with men (MSM) in Dublin, an Outbreak Control Team (OCT) was set up in late 2000. The outbreak peaked in 2001 and had largely ceased by late 2003. An enhanced syphilis surveillance system was introduced to capture data from January 2000. Between January 2000 and December 2003, 547 cases of infectious syphilis were notified in Ireland (415 were MSM). Four per cent of cases were diagnosed with HIV and 15.4% of cases were diagnosed with at least one other STI (excluding HIV) within the previous 3 months. The mean number of contacts reported by male cases in the 3 months prior to diagnosis was 4 (range 0-8) for bisexual contacts and 6 for homosexual contacts (range 1-90). Thirty one per cent of MSM reported having had recent unprotected oral sex and 15.9% of MSM reported having had recent unprotected anal sex. Sixteen per cent of cases reported having had sex abroad in the three months prior to diagnosis. The results suggest that risky sexual behaviour contributed to the onward transmission of infection in Dublin. The outbreak in Dublin could be seen as part of a European-wide outbreak of syphilis. The rates of co-infection with HIV and syphilis in Ireland are comparable with rates reported from other centres. There is a need to improve surveillance systems in order to allow real time evaluation of interventions and ongoing monitoring of infection trends.

Evaluation of Second Generation Amiloride Analogs as Therapy for Cystic Fibrosis Lung Disease

Epithelial sodium channel (ENaC) blockers have been proposed as a therapy to restore mucus clearance (MC) in cystic fibrosis (CF) airways. The therapeutic effects of the first generation ENaC blocker, amiloride, in CF patients, however, were minimal. Because the failure of amiloride reflected both its low potency and short duration of action on airway surfaces, we investigated whether the increased potency of benzamil and phenamil would produce more favorable pharmacodynamic properties. In vitro potency, maximal efficacy, rate of recovery from maximal block of ENaC, and rate of drug absorption were compared for amiloride, benzamil, and phenamil in cultured human and ovine bronchial epithelial cells. In both human and ovine bronchial epithelia, the rank order of potency was benzamil > phenamil >> amiloride, the maximal efficacy was benzamil = phenamil = amiloride, the recovery to baseline sodium transport was phenamil < benzamil << amiloride, and the rate of drug absorption was phenamil > benzamil >> amiloride. Based on greater potency, benzamil was compared with amiloride in in vivo pharmacodynamic studies in sheep, including tracheal mucus velocity (TMV) and MC. Benzamil enhanced MC and TMV, but acute potency or duration of effect did not exceed that of amiloride. In conclusion, our data support the hypothesis that ENaC blocker aerosol therapy increases MC. However, rapid absorption of benzamil from the mucosal surface offset its greater potency, making it equieffective with amiloride in vivo. More potent, less absorbable, third generation ENaC blockers will be required for an effective aerosol CF pharmacotherapy.

Resurgence in infectious syphilis in Ireland: an epidemiological study

INTRODUCTION

In 2000, a syphilis outbreak was identified in Ireland.

MATERIALS AND METHODS

A prospective enhanced database was established in 2000. Crude incidence rates for the general population, men who have sex with men (MSM), and HIV-positive MSM were calculated.

RESULTS

Three hundred fifty-six cases of infectious syphilis were diagnosed at 1 center. Eighty-five percent of cases were identified as MSM. Crude incidence rates in MSM, ranging in age between 20 and 44 years, peaked in 2001 at 719 cases per 100000 of the MSM population. A total of 17.4% of cases occurred in HIV-infected individuals. Crude incidence rates of syphilis in HIV-positive MSM in the center increased to 7280 per 100000. Similar percentages of MSM with and without HIV infection had unprotected anal intercourse (37% and 41%, respectively).

CONCLUSION

High-risk sexual behavior continues among HIV-infected and -noninfected MSM. Crude incidence rates among MSM in Ireland are alarming when compared with other outbreaks.

Positive surveillance blood culture is a predictive factor for secondary metastatic infection in patients with Staphylococcus aureus bacteraemia

PURPOSE

Staphylococcus aureus bacteraemia (SAB) may be complicated by secondary metastatic infection such as endocarditis, osteomyelitis or septic arthritis. This cohort study aimed to assess the prognostic value of sustained bacteraemia for outcomes related to Staphylococcus aureus bacteraemia.

SUBJECTS AND METHODS

The study took place in three tertiary-care, university-affiliated hospitals. Patients were prospectively included if they agreed to participate and if the following data were available: (a). surveillance blood culture taken between 24 and 48 h after commencement of effective antibiotic therapy; (b). appropriate investigations (at least a TTE) performed as suggested by the infectious diseases consult service. Patients with sustained bacteraemia defined as persistent positive blood cultures more than 24 h after commencement of effective antibiotic therapy were compared to patients for whom the surveillance blood culture was negative.

RESULTS

One hundred and four patients were enrolled, including 51 patients diagnosed with sustained bacteraemia. Sustained bacteraemia was significantly associated with a higher frequency of secondary metastatic infection (p<0.001) and with a higher frequency of CRP>100 mg/l. Frequency of acute complications due to infection, septic shock and death due to bacteraemia was higher for patients with sustained bacteraemia but this difference was not statistically significant. Using a Cox model, the risk for death associated with sustained SAB, controlling for Index of comorbidity and age (categorised as<or>or=70 years), was 1.2 (95% CI: (0.5, 3); p>0.05).

CONCLUSION

In conclusion, surveillance blood cultures, especially performed on effective antibiotic therapy, may be a simple and cost-effective way to select a population at risk for secondary metastatic infection from SAB.

Assessing limiting factors to the acceptance of antiretroviral therapy in a large cohort of injecting drug users

OBJECTIVE

A comprehensive questionnaire was designed to assess the knowledge and understanding of injecting drug users (IDUs) regarding their HIV disease, and to determine any factors that may increase the acceptance of antiretroviral therapy (ART) by this group.

RESULTS

Twenty percent of the total IDU cohort attending the GUIDE (GenitoUrinary Medicine and Infectious Diseases) clinic participated in the study. Fifty-two percent had been homeless in the past 5 years and 84% are unemployed. Seventy-two percent of patients did not complete second level education and 10% were illiterate. Fifty-one percent had siblings or parents with a history of injection drug misuse, and 25% had at least one sibling also HIV positive. Forty-seven percent started using drugs before the age of 13 years, and the most common initial drug was heroin (44%). Ninety-five percent had attended for methadone maintenance therapy (MMT), with 39% currently attending for daily therapy. The majority of patients were unable to simply explain or interpret CD4 cell counts (54%) and 'viral loads' (65%). Fifty-seven percent of patients were receiving highly active antiretroviral therapy (HAART). There was a statistically significant association between patients receiving HAART and both attendance at a primary care physician for methadone maintenance therapy (P = 0.005), and weekly take-outs of methadone (P = 0.005). There was also an association between adherence to HAART and attendance at a methadone maintenance clinic (P = 0.04).

CONCLUSIONS

This study highlights the chaotic lifestyle and complex social background of the IDU. Such factors were not, however, associated with acceptance of HAART. The primary factor associated with both the acceptance of and adherence to HAART was regular and stable attendance for methadone therapy.

The impact of changes in private health expenditure on New Zealand households

The proportion of New Zealand's total health expenditure financed by the public sector has fallen from 87% in 1983/84 to 77% in 1997/98 in real per capita terms. In the paper, we firstly describe changes in private health expenditure in New Zealand and compare these changes with trends in private and public health expenditure in a number of OECD countries. Secondly, we find that in New Zealand, there have been increases in both out-of-pocket payments and membership of private health insurance funds over the period from 1983/84 to 1997/98. We analyze the relationship between out-of-pocket expenditure, insurance expenditure, and household income across income deciles and across time. We find that out-of-pocket payments are regressive but the regressivity did decline in 1993/94 in response to a government initiative to improve the targeting of government subsidies towards lower income households.

The great pretender returns to Dublin, Ireland

BACKGROUND

An outbreak of syphilis has been identified primarily in Dublin, Ireland. On a background of a stable low incidence of syphilis, a significant increase in the number of cases of syphilis has been observed over the past 18 months.

RESULTS

181 cases of syphilis were seen in this period. 121 were defined as early syphilis. These cases were mainly among men who have sex with men (92%). A high rate of HIV co-infection was present; 16 patients who regularly attended HIV clinics were diagnosed with early syphilis. Nine patients were co-diagnosed with HIV and early syphilis. High risk behaviour and concurrent diagnoses with other sexually transmitted infections were prevalent in this cohort. Sexual networks were also investigated.

CONCLUSION

An education campaign, widespread advertisements, and on-site testing in commercial venues have revealed further cases. Safer sex messages need to be emphasised particularly among the HIV population. Further innovative strategies continue to be explored.

The changing epidemiology of HIV infection in injecting drug users in Dublin, Ireland

INTRODUCTION

Injecting drug users (IDUs) represent 41.6% of the total cohort of HIV-infected patients in Ireland. Between January 1999 and December 2000, referrals to the largest tertiary centre for HIV infection in Dublin have increased dramatically. This has occurred on a background of a reduction in the overall incidence of HIV infection in Ireland between 1990 and 1998. Here we describe the changing epidemiology of HIV disease in IDUs and explore potential aetiological factors.

METHODS

This is a retrospective study, collecting all data relating to new HIV diagnoses occurring in IDUs, referred to the GenitoUrinary Medicine and Infectious Diseases (GUIDE) clinic between 1987 and 2000. We calculated 6-month incidence rates of new HIV diagnoses in IDUs referred to the GUIDE clinic and performed a more detailed analysis of those patients diagnosed between January 1999 and December 2000, documenting age, sex, time and place of diagnosis, drug use history and primary drug of misuse, needle sharing history, attendance at a drug treatment clinic, prior HIV testing history, hepatitis B and hepatitis C status, and CD4 cell counts and HIV RNA levels at diagnosis.

RESULTS

The number of new HIV diagnoses in IDUs increased fivefold between 1995 and 2000. Moreover, 40% of patients diagnosed since then have been under 22 years old. There has also been a significant reversal of the initial male to female ratio seen in the initial epidemic of the 1980s.

CONCLUSION

There has been a significant increase in the incidence of HIV infection in IDUs between 1995 and 2000. Similar trends have been described recently in other risk groups. The aetiology of these trends is multifactorial, and a multidisciplinary, rejuvenated approach is required to focus on improving health education to reduce both sexual and needle sharing practices.

An analysis of gene-finding programs for Neurospora crassa

MOTIVATION

Computational gene identification plays an important role in genome projects. The approaches used in gene identification programs are often tuned to one particular organism, and accuracy for one organism or class of organism does not necessarily translate to accurate predictions for other organisms. In this paper we evaluate five computer programs on their ability to locate coding regions and to predict gene structure in Neurospora crassa. One of these programs (FFG) was designed specifically for gene-finding in N.crassa, but the model parameters have not yet been fully 'tuned', and the program should thus be viewed as an initial prototype. The other four programs were neither designed nor tuned for N.crassa.

RESULTS

We describe the data sets on which the experiments were performed, the approaches employed by the five algorithms: GenScan, HMMGene, GeneMark, Pombe and FFG, the methodology of our evaluation, and the results of the experiments. Our results show that, while none of the programs consistently performs well, overall the GenScan program has the best performance on sensitivity and Missing Exons (ME) while the HMMGene and FFG programs have good performance in locating the exons roughly. Additional work motivated by this study includes the creation of a tool for the automated evaluation of gene-finding programs, the collection of larger and more reliable data sets for N.crassa, parameterization of the model used in FFG to produce a more accurate gene-finding program for this species, and a more in-depth evaluation of the reasons that existing programs generally fail for N.crassa.

AVAILABILITY

Data sets, the FFG program source code, and links to the other programs analyzed are available at http://jerry.cs.uga.edu/~wang/genefind.html.

CONTACT

eileen@cs.uga.edu.

Differences in eating pattern labels between maintainers and nonmaintainers in the Women's Health Initiative

OBJECTIVE

To describe how a sample of women in the Women's Health Initiative Dietary Modification Trial (WHIDM) labeled a healthy eating pattern and to compare these labels to their dietary maintenance.

DESIGN

Participants completed a food frequency questionnaire and were divided into two maintenance groups, based on the percentage of energy derived from fat in their diets. Individual, semistructured interviews with the same subjects elicited information on labels they use to describe a healthy eating pattern.

SUBJECTS/SETTINGS

Subjects were 100 postmenopausal women, 50 to 79 years of age, free of breast and colorectal cancer, and participating in a dietary intervention that consisted of 20% or less energy from fat.

MAIN OUTCOME MEASURES

Percentage of energy from fat in the diet and labels used to define a healthy eating pattern.

STATISTICAL ANALYSES PERFORMED

Multivariate analysis.

RESULTS

The label "consistent/patterned" was a predictor of dietary nonmaintenance (p <.05).

IMPLICATIONS

Future studies should use this information to re-educate nonmaintainers on compliance issues.

Public hospitals and substance abuse services for pregnant women and mothers: implications for managed-care programs and Medicaid

Although an increasing proportion of the US population receives health services through managed care, pregnant women and mothers eligible for Medicaid who are involved with alcohol or other drugs are often excluded from these programs due in large part to lack of information on costs, service needs, and service use. To develop such information policy, service settings, and managed-care plans, the project conducted a national survey using a provider group with experience in caring for this population, the member universe of the National Association of Public Hospitals and Health Systems. The survey requested detailed information on hospital system information, current managed-care arrangements, outcome measurements, financing, service priorities, and service availability. The 81% response rate (n = 95) identified 35 hospital systems providing services to an average of 998 women in 1997. The majority of these systems (69%) reported coordinating care for these patients, but only 26% reported they computerize patient charts. Most use at least one indicator to measure effectiveness, and 50% use at least four. Counseling/education and transportation were seen as key support services, but many acknowledge they are not reimbursed for critical services such as nutrition education. The discussion highlights the need to provide formal support for core support services, to assist in care coordination and provide incentives for developing more sophisticated information, and to specify related services in the state Medicaid contract language.

Changing concepts in long-term central venous access: catheter selection and cost savings

BACKGROUND AND OBJECTIVES

Long-term central venous access is becoming an increasingly important component of health care today. Long-term central venous access is important therapeutically for a multitude of reasons, including the administration of chemotherapy, antibiotics, and total parenteral nutrition. Central venous access can be established in a variety of ways varying from catheters inserted at the bedside to surgically placed ports. Furthermore, in an effort to control costs, many traditionally inpatient therapies have moved to an outpatient setting. This raises many questions regarding catheter selection. Which catheter will result in the best outcome at the least cost? It has become apparent in our hospital that traditionally placed surgical catheters (ie, Hickmans and central venous ports) may no longer be the only options. The objective of this study was to explore the various modalities for establishing central venous access comparing indications, costs, and complications to guide the clinician in choosing the appropriate catheter with the best outcome at the least cost.

METHODS

We evaluated our institution's central venous catheter use during a 3-year period from 1995 through 1997. Data was obtained retrospectively through chart review. In addition to demographic data, specific information regarding catheter type, placement technique, indications, complications, and catheter history were recorded. Cost data were obtained from several departments including surgery, radiology, nursing, anesthesia, pharmacy, and the hospital purchasing department.

RESULTS

During a 30-month period, 684 attempted central venous catheter insertions were identified, including 126 surgically placed central venous catheters, 264 peripherally inserted central catheters by the nursing service, and 294 radiologically inserted peripheral ports. Overall complications were rare but tended to be more severe in the surgical group. Relative cost differences between the groups were significant. Charges for peripherally inserted central catheters were $401 per procedure, compared with $3870 for radiologically placed peripheral ports and $3532 to $4296 for surgically placed catheters.

CONCLUSIONS

Traditional surgically placed central catheters are increasingly being replaced by peripherally inserted central venous access devices. Significant cost savings and fewer severe complications can be realized by preferential use of peripherally inserted central catheters when clinically indicated. Cost savings may not be as significant when comparing radiologically placed versus surgically placed catheters. However, significant cost savings and fewer severe complications are associated with peripheral central venous access versus the surgical or radiologic approach.

Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors

The association between needle exchange, change in drug use frequency and enrollment and retention in methadone drug treatment was studied in a cohort of Seattle injection drug users (IDUs). Participants included IDUs classified according to whether they had used a needle exchange by study enrollment and during the 12-month follow-up period. The relative risk (RR) and the adjusted RR (ARR) were estimated as measures of the association. It was found that IDUs who had formerly been exchange users were more likely than never-exchangers to report a substantial (> or= 75%) reduction in injection (ARR = 2.85, 95% confidence limit [CL] 1.47-5.51), to stop injecting altogether (ARR = 3.5, 95% CL 2.1-5.9), and to remain in drug treatment. New users of the exchange were five times more likely to enter drug treatment than never-exchangers. We conclude that reduced drug use and increased drug treatment enrollment associated with needle exchange participation may have many public health benefits, including prevention of blood-borne viral transmission.

Delivery systems and adjuvants for vaccination against HIV

Epidemiologic studies have revealed that HIV-1 infections occur through contact with contaminated blood or during unprotected vaginal or anal intercourse. Hence, to protect against HIV infection, vaccines should induce both mucosal and systemic immune responses. We present a brief review of the different delivery systems and adjuvants which can be used to elicit mucosal immune responses. Oral or nasal administration of recombinant Salmonella vaccines can induce both mucosal and systemic immune responses against the carried antigen. The oral delivery of mucosal adjuvants (such as cholera toxin) in association with antigens has been shown to enhance mucosal and systemic immune responses against them. Recently developed vaccination strategies using naked DNA or recombinant adenovirus are also discussed.

Observation of harmonic generation and nonlinear coupling in the collective dynamics of a bose-einstein condensate

We report the observation of harmonic generation and strong nonlinear coupling of two collective modes of a condensed gas of rubidium atoms. Using a modified time averaged orbiting potential trap we changed the trap anisotropy to a value where the frequency of the m = 0 high-lying mode corresponds to twice the frequency of the m = 0 low-lying mode, thus leading to strong nonlinear coupling between these modes. By changing the anisotropy of the trap and exciting the low-lying mode we observed significant frequency shifts of this fundamental mode and also the generation of its second harmonic.

Development of analytical methods for the detection of metaraminol in the horse

Aramine (metaraminol bitartrate) has been found in the possession of horse trainers and veterinarians who have been investigated for possible inappropriate drug administration to racing horses. Metaraminol (3-hydroxyphenylisopropanolamine) is a sympathomimetic amine that directly and indirectly affects adrenergic receptors, with alpha effects being predominant. Because it has the potential to affect the performance of a racing horse, its use is prohibited. In the present study, methods for the detection of metaraminol were developed. Metaraminol was found to be extracted with poor recovery (< 50%) from aqueous solutions by routine basic extraction or cation exchange/reversed-phase solid-phase extraction techniques. However, an extractive acetylation method gave good (> 90%) recovery of metaraminol from aqueous samples. Sequential urine samples collected from horses administered metaraminol intramuscularly at 0.02, 0.10, and 0.23 mg/kg were extracted by the developed extractive acetylation procedure and analyzed by gas chromatography-mass spectrometry (GC-MS) in full-scan and selected ion monitoring modes. Norphenylephrine was used as an internal standard for quantitative analysis. The maximum concentration of metaraminol occurred between 1 and 2 h postadministration. Metaraminol was detected in the 0.23 mg/kg administration urine for 24 h postadministration. Metaraminol was detected for the 0.10 and 0.02 mg/kg doses for approximately 8 h postadministration. No apparent biotransformation products were observed in a reaction mixture of metaraminol and horse liver microsomal reaction mixture. Comparison of gas chromatograms of the extracts of the postadministration urine samples with those of the pre-administration samples failed to reveal any exogenous compound other than metaraminol.

Inequalities in health: raising awareness among health authority staff

A postal survey of all staff working for Bro Taf Health Authority (n = 237) was carried out during August and September 1998. The survey was concerned with tackling inequalities in health in terms of involvement, information needs, priorities and working patterns. The aim was to raise awareness of the Health Authority's commitment to tackling inequalities in health and to collect employees' opinions on methods of working effectively towards greater equity. The response rate was higher for senior grades (63%) than for basic grades (26%). Not all employees had access to background documents and many expressed a need for more information. There was a strong feeling that a change in working patterns would be beneficial and staff were particularly concerned that internal communications should be improved. The survey provided a good opportunity to raise awareness of health inequality issues and was beneficial in providing an opportunity for staff to express their opinions anonymously. Some suggestions have already been implemented and others are incorporated in the Health Authority's Equity Strategy.

A discussion of the legal aspects of female genital mutilation

The purpose of this paper is to examine the position of the nurse/midwife in the United Kingdom when involved with the care of a woman or female child who has suffered genital mutilation, which is an illegal practice in this country and most other areas of the world. The types of circumcision commonly practised are introduced, the prevalent reasons for the continuation of the practice among certain ethnic groups are presented, and the range of issues to be considered by the nurse is examined. These include international and national legal aspects which do not exist in isolation and are considered in context with cultural, medical, human rights and gender issues. Nursing legal issues include child protection, consent, advocacy and confidentiality, which invoke the Code Of Professional Conduct of the United Kingdom Central Council for Nursing Midwifery & Health Visiting. Midwives and nurses working in the field of gynaecology have raised questions regarding possible courses of action to take when presented with this issue. Increased knowledge can help to inform those decisions. Therefore, implications for future practice are addressed, together with recommendations to assist nurses with decision making when faced with this scenario in the future.

The nature of the attenuation of Salmonella typhimurium strains expressing human papillomavirus type 16 virus-like particles determines the systemic and mucosal antibody responses in nasally immunized mice

We have recently shown by using a recombinant Salmonella typhimurium PhoPc strain in mice the feasibility of using a Salmonella-based vaccine to prevent infection by the genital human papillomavirus type 16 (HPV16). Here, we compare the HPV16-specific antibody responses elicited by nasal immunization with recombinant S. typhimurium strains harboring attenuations that, in contrast to PhoPc, are suitable for human use. For this purpose, chi4989 (Deltacya Deltacrp) and chi4990 [Deltacya Delta(crp-cdt)] were constructed in the ATCC 14028 genetic background, and comparison was made with the isogenic PhoPc and PhoP- strains. Although the levels of expression of HPV16 virus-like particle (VLP) were similar in all strains, only PhoPc HPV16 induced sustained specific antibody responses after nasal immunization, while all strains induced high antibody responses with a single nasal immunization when an unrelated viral hepatitis B core antigen was expressed. The level of the specific antibody responses induced did not correlate with the number of recombinant bacteria surviving in various organs 2 weeks after immunization. Our data suggest that the immunogenicity of attenuated Salmonella vaccine strains does not correlate with either the number of persisting bacteria after immunization or the levels of in vitro expression of the antigen carried. Rather, the PhoPc phenotype appears to provide the unique ability in Salmonella to induce immune responses against HPV16 VLPs.