Health care use by human immunodeficiency virus-infected students at a California student health service

We report characteristics of 16 college students with human immunodeficiency virus (HIV) infection but without the acquired immunodeficiency syndrome who received care at a student health center at a major university in California. Sociodemographic and clinical data and medical expenditures were obtained retrospectively from medical charts and computerized billing records. All 16 students were men who had sex with men, and 3 had also used intravenous drugs. Dermatologic conditions, upper respiratory tract infections, gastrointestinal conditions, anemia, lymphadenopathy, sexually transmitted diseases, and ophthalmologic conditions were more frequent among HIV-infected students than among the general student population using the health center. On average, HIV-infected students visited the student health service about 3 times more often and incurred charges about 10 times higher than the general population of students visiting the health center. Student health centers, which have been at the forefront of developing strategies for HIV prevention, education, and counseling, must also develop treatment programs for HIV-infected students.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) as adjunct therapy in relapsed Hodgkin disease

OBJECTIVE

To determine the clinical and economic effects of granulocyte macrophage colony-stimulating factor (GM-CSF) as adjunct therapy in relapsed or refractory Hodgkin disease.

DESIGN

A randomized, double-blind, phase III clinical trial.

SETTING

A tertiary referral center.

PATIENTS

Twenty-four patients (twelve of whom were controls) treated with high-dose chemotherapy and autologous bone marrow transplantation.

MAIN RESULTS

The 12 patients treated with GM-CSF, when compared with placebo recipients, had shorter periods of neutropenia (median duration of an absolute neutrophil count of less than 1000 cells/mm3, 16 days compared with 27 days; P = 0.02), shorter periods of platelet-transfusion dependency (median duration, 13.5 days compared with 21 days; P = 0.03), and shorter hospitalizations (median hospital stay, 32 days compared with 40.5 days; P = 0.004). Other clinical outcomes, such as frequency and severity of toxicities, development of pneumonia or infection, in-hospital death, and response rate were similar in the two groups. Actuarial long-term disease-free survival was 64% for patients treated with GM-CSF and 58% for patients who received placebo after 32 months of follow-up (P = 0.15). The group treated with GM-CSF had lower total charges after infusion of autologous marrow than the placebo group (median in-hospital charges, $39,800 compared with $62,500; P = 0.005) because of lower post-infusion charges for room and board, antibiotic therapy, transfusions, laboratory tests, and physical therapy visits.

CONCLUSIONS

Administration of GM-CSF was associated with acceleration of myeloid and platelet recovery and was cost effective in the treatment of patients with relapsed Hodgkin disease who received intensive chemotherapy.

Medical care for AIDS: cost planning

The author discusses various improvements made in the treatment of persons with AIDS, and how the advancements will affect decisions made by materiel managers.

Patterns of care related to age of men with prostate cancer

A chart review study was done of 242 Stages A2 to D1 cancer patients to determine whether the age of patients with prostate cancer influenced their physicians' management strategies. Ten hospitals of varying size, medical-school affiliation, and patient socioeconomic status participated in this study. Patterns of prostate cancer care were examined using sets of branching logic standards in the form of criteria maps. A chart-based comorbidity index was used to control for the effect of coexisting diseases on cancer management. Regression models indicated that patient age affected the intensity of both the diagnostic evaluation and therapy, even after controlling for independent factors such as comorbid disease and individual hospital differences. Patients aged 75 years and older had significantly less intensive clinical staging workups and use of surgical and radiation therapies compared with patients aged 65 to 74 years and patients aged 50 to 64 years. In conjunction with similar results noted in studies of elderly patients with other malignancies, these results suggest that age bias is likely to be widespread. Physicians need to consider life expectancy, the ability of the patient to tolerate diagnostic procedures and therapies, and the quality of life in making treatment decisions.

The relation between hospital experience and in-hospital mortality for patients with AIDS-related PCP

There is marked debate by physicians and policymakers regarding the creation of regionalized acquired immunodeficiency syndrome (AIDS) centers. A central issue is whether outcomes of care, particularly mortality, differ as a function of hospital experience with patients with AIDS. We evaluated the experience of 257 patients with AIDS and Pneumocystis carinii pneumonia treated at 15 California hospitals between October 1986 and October 1987. An overall 15.2% in-hospital mortality rate was observed. However, a markedly lower in-hospital mortality rate was observed in the group of patients treated at hospitals that had a high level of experience with patients with AIDS (greater than or equal to 30 human immunodeficiency virus-related discharges per 10,000 hospital discharges) relative to the group treated at hospitals with less experience (less than 30 human immunodeficiency virus-related discharges per 10,000 hospital discharges): 12% vs 33%. Other factors significantly associated with in-hospital mortality included intensive care unit use, admission from an emergency department or through an interhospital transfer, and a history of hospitalizations. A logistic regression model indicated that, after controlling for severity indicators, AIDS experience remained significantly related to mortality. Our findings suggest that policymakers should consider three options: creating regional AIDS centers, implementing policies that promote a rapid but carefully monitored increase in experience of low-volume hospitals with human immunodeficiency virus-infected individuals, or providing highly focused educational efforts at low-AIDS-experience facilities. Without such policy initiatives, differences in mortality rates like those we have found might persist as cases of AIDS begin to occur in every area of the country.

Phase I clinical and pharmacological study of 72-hour continuous infusion of etoposide in patients with advanced cancer

Etoposide (VP-16) is a semisynthetic epipodophyllotoxin that exhibits cell cycle phase specific cytotoxicity and enhanced effectiveness with increasing duration of drug exposure. We have therefore conducted a Phase I trial to determine the side effects, tolerable doses, and pharmacokinetic parameters of VP-16 given by continuous i.v. infusion to patients with advanced cancer. Eighteen patients were treated with varying dosages of VP-16 infused continuously for 72 consecutive hours every 28 days. Using this schedule, the maximally tolerated dosage of VP-16 was 150 mg/m2/day for patients with good performance status and 125 mg/m2/day for more debilitated cancer patients. Hematological toxicity was dose limiting with median granulocyte and platelet nadirs of 700/mm3 and 116,000/mm3, respectively, at a dose of 150 mg/m2/day. Other toxicities included only mild nausea, vomiting, and alopecia. Plasma and urine VP-16 concentrations were determined using a high-performance liquid chromatography assay. At a VP-16 dosage of 150 mg/m2/day, steady-state VP-16 concentrations were in the range of 2.1 to 7.0 micrograms/ml in all patients. Further pharmacokinetic analysis revealed that the plasma clearance of VP-16 was consistently near 25 ml/min/m2 (independent of dosage) and that renal clearance accounted for only 15% of VP-16 total plasma clearance. Patient age was found to be the most important factor correlating with plasma clearance of VP-16. Linear regression analysis also revealed that both the plasma VP-16 concentration at steady state and the concentration of VP-16 in plasma at 24 h from the start of the infusion correlated with hematological toxicity; no other patient characteristics correlated with hematological toxicity. The recommended VP-16 dose for Phase II trials of 72-h continuous infusion VP-16 is 150 mg/m2/day in patients with good performance status.

Hairy cell leukemia and mucormycosis. Treatment with alpha-2 interferon

Right maxillary sinus mucormycosis developed in a 45-year-old patient with hairy cell leukemia and pancytopenia. The patient recovered with surgical debridement, amphotericin therapy, and institution of alpha-2 interferon as therapy for his hairy cell leukemia. This may be the first case of the use of alpha-2-interferon therapy in a patient with documented systemic fungal infection and hairy cell leukemia and a rare example of recovery from this infection in a hematologic malignancy.

Hyponatremia and other toxic effects during a phase I trial of recombinant human gamma interferon and vinblastine

Recombinant human gamma interferon (Biogen) and vinblastine were administered in a phase I study. Side effects included fever and chills, nausea and vomiting, acute symptomatic hyponatremia, reversible myelosuppression, hepatitis, transient hypotension, congestive heart failure, renal insufficiency, and nonselective proteinuria. In most patients, additional host factors contributed to these toxic effects. Side effects occurred despite dose reduction; therefore, protocol accrual was prematurely closed. No correlation between serum concentrations and toxicity was noted. Median serum vinblastine concentration was 1.04 ng/ml; median serum interferon concentration was 17.3 IU/ml.

Staging and therapy of orbital lymphomas

Ten patients with non-Hodgkin's lymphoma primarily affecting the orbital region were evaluated at Michael Reese Hospital and Medical Center, Chicago, between 1976 and 1983. Diagnoses were based on the histopathologic classification systems of the Working Formulation of the Non-Hodgkin's Lymphomas and Rappoport. Sequential staging procedures performed at the time of diagnosis included liver-spleen scans, Technecium-99 bone scans, gallium 67 scans, computerized axial tomograms of the orbit and abdomen, bone marrow examination and cerebral spinal fluid analyses. Adverse prognostic factors included the following: orbital bone erosions, Stage IV disease, and large cell or mixed cell, diffuse histologic features. The type of histopathologic findings combined with the results of sequential staging procedures is useful in identifying those patients who would benefit most from systemic chemotherapy.

Discovery of a New Gravitational Lens System

A new gravitational lens system, the triple radio source MG2016+112, has been discovered. Five emission lines at a redshift of 3.2733+/-0.0014 have been identified in the spectra of two stellar objects of magnitude 22.5 coincident with radio components 3.4 arc seconds apart. The lines are the narrowest ever observed in objects at such a large redshift. The redshift of a 23rd-magnitude extended optical object coincident with the third radio component has not been determined spectroscopically, but its known optical properties are consistent with those of a giant elliptical galaxy with a redshift of about 0.8.

Demonstration of presbycusis across repeated measures in a nonhuman primate species

The progress of age-related hearing loss in three 31-yr-old, two 24-yr-old, and two 9-yr-old rhesus monkeys (Macaca mulatta) was repeatedly examined over a period of 3 yr. Pure-tone audiograms for seven frequencies, .125, .500, 2.000, 4.000, 16.000, 22.667, and 32.000 kHz, were obtained through the use of the psychophysical tracking method. Analysis indicated the presence of presbycusis in the older animals. Animals demonstrating presbycusis showed a progressive decrement in the ability to detect higher frequencies and an overall hearing loss at all frequencies.

Demonstration of presbycusis across repeated measures in a nonhuman primate species

The progress of age-related hearing loss in three 31-yr-old, two 24-yr-old, and two 9-yr-old rhesus monkeys (Macaca mulatta) was repeatedly examined over a period of 3 yr. Pure-tone audiograms for seven frequencies, .125, .500, 2.000, 4.000, 16.000, 22.667, and 32.000 kHz, were obtained through the use of the psychophysical tracking method. Analysis indicated the presence of presbycusis in the older animals. Animals demonstrating presbycusis showed a progressive decrement in the ability to detect higher frequencies and an overall hearing loss at all frequencies.

Radiocarbon Dating with Electrostatic Accelerators: Dating of Milligram Samples

The recently developed direct counting technique for radiocarbon atoms has been used to measure the relative numbers of such atoms in various geological samples which had earlier been dated by the beta-ray counting method. Sample weights ranged from 3.5 to 15 milligrams. The dates determined by the two methods are consistent with each other. Further experience with the new method is also reported.

Radiocarbon Dating Using Electrostatic Accelerators: Negative Ions Provide the Key

Mass spectrometric methods have long been suggested as ways of measuring (14)C/(12)C ratios for carbon dating. One problem has been to distinguish between (14)N and (14)C. With negative ions and a tandem electrostatic accelerator, the (14)N background is virtually absent and fewer than three (14)C atoms in 10(16) atoms of (12)C have been easily measured.