Assessing effects of behavioral intervention on treatment outcomes among patients initiating HIV care: Rationale and design of iENGAGE intervention trial

During the initial year of HIV diagnosis, while patients are often overwhelmed adjusting to this life changing diagnosis, they must develop self-care behaviors for attending regular medical care visits and antiretroviral therapy (ART) adherence to achieve and sustain viral suppression (VS). Maintaining "HIV adherence" and integrating it into one's daily life is required to sustain VS over time. The HIV care continuum or "treatment cascade," an epidemiological snapshot of the national epidemic in the United States (US), indicates that a minority of persons living with HIV (PLWH) have achieved VS. Little evidence exists regarding the effects of interventions focusing on PLWH newly initiating outpatient HIV care. An intervention that focuses on both retention in care and ART adherence skills delivered during the pivotal first year of HIV care is lacking. To address this, we developed a theory-based intervention evaluated in the Integrating Engagement and Adherence Goals upon Entry (iENGAGE) study, a National Institute of Allergy and Infectious Diseases (NIAID) funded randomized behavioral intervention trial. Here we present the study objectives, design and rationale, as well as the intervention components, targeting rapid and sustained VS through retention in HIV care and ART adherence during participants' first year of HIV care. The primary outcome of the study is 48-week VS (<200 c/mL). The secondary outcomes are retention in care, including HIV visit adherence and visit constancy, as well as ART adherence.

Frequency of small-colony variants and antimicrobial susceptibility of methicillin-resistant Staphylococcus aureus in cystic fibrosis patients

BACKGROUND

Small-colony variants (SCVs) are a distinct phenotype of Staphylococcus aureus, known for their role in chronic, difficult to treat infections, including cystic fibrosis (CF) lung disease. The goal of this study was to characterize SCV MRSA infection in an adult and pediatric CF population and to identify antibiotic susceptibility patterns unique to SCV MRSA.

METHODS

We recovered methicillin-resistant S. aureus (MRSA) from respiratory culture samples from CF patients at the Johns Hopkins Hospital during a 6month study period.

RESULTS

Of 1161 samples, 200 isolates (17%) were identified as MRSA, and 37 isolates from 28 patients were identified as SCV MRSA. A higher proportion of MRSA was found among SCV isolates (37/66, 56%) compared to normal colony variant (NCV) isolates (163/417, 39%), p=0.02. All SCV MRSA isolates from individual patients were susceptible to vancomycin and ceftaroline, but they demonstrated higher rates of antibiotic resistance to trimethoprim/sulfamethoxazole, moxifloxacin, and erythromycin, compared to NCV MRSA isolates. Additionally, individuals with SCV MRSA had lower lung function, higher rates of persistent MRSA infection, and higher rates of previous antibiotic use, compared to individuals with NCV MRSA.

CONCLUSIONS

A significant proportion of MRSA isolates recovered from patients with CF have the SCV morphology. Compared to individuals with NCV MRSA, those with SCV MRSA have higher rates of persistent MRSA infection and lower lung function. SCV MRSA isolates were more resistant than NCV, but they are highly susceptible to vancomycin, linezolid and ceftaroline.

The rapid access chest pain clinic: unmet distress and disability

AIMS

To determine the characteristics, clinical needs and level of health-care use of patients with non-cardiac (NCCP) and cardiac-chest pain (CCP) attending a Rapid Access Chest Pain Clinic in an inner-London Hospital.

METHODS

A cross-sectional comparison of NCCP and CCP patients on measures of pain, mood, beliefs, somatic symptoms and use of services completed by patients attending the Rapid Access Chest Pain Clinic over an 18-month period.

RESULTS

There were no significant differences between NCCP and CCP patients in terms of chest pain frequency, duration or severity or associated distress; however, NCCP were younger (53 vs. 60, OR = 1.05) and reported 'atypical' pain more frequently (82% vs. 50%, OR = 3.72). The NCCP group reported more panic-type beliefs about chest pain (5.8 vs. 4.3, P < 0.05) and lower 'illness coherence' (a patient's belief that the illness 'makes sense') (3.5 vs. 4.7, P < 0.05). Anxiety and depression scores were similar in both groups. Both groups had similar levels of health-care use but patients with NCCP saw more types of health-care worker (mean 1.7) than those with CCP (mean 1.4, P < 0.05).

CONCLUSION

Patients with NCCP are as disabled and distressed as patients with CCP however current services fail to meet their needs. We suggest that a biopsychosocial approach should be explored.

The effect of applying NICE guidelines for the investigation of stable chest pain on out-patient cardiac services in the UK

BACKGROUND

The National Institute for Health and Clinical Excellence (NICE) recently released guidelines for the investigation of chest pain of recent onset. There is no published data regarding their impact on out-patient cardiac services.

AIM

This study was undertaken to assess the likelihood of coronary artery disease (CAD) in Rapid Access Chest Pain Clinic (RACPC) patients and the resultant investigation burden if NICE guidance was applied.

METHODS

Five hundred and ninety-five consecutive patients attending two RACPCs over 6 months preceding release of the NICE guidelines [51% male; median age 55 (range 22-94) years] were risk stratified using NICE criteria and the resultant investigations evaluated.

RESULTS

One hundred and six (18%) patients had a likelihood of CAD <10%, 123 (21%) between 10% and 29%, 175 (29%) between 30% and 60%, 141 (24%) between 61% and 90% and 50 (8%) >90%. NICE would have recommended 443 (74%) patients for no cardiac investigation, 10 (2%) for cardiac computed tomography (CCT), 69 (12%) for functional cardiac testing and 73 (12%) for invasive angiography. Relative to existing practice, there would have been a trend towards reduced functional cardiac testing (-24%, P = 0.06), no significant change in CCT (43%, P = 0.436) and a significant increase in invasive angiography (508%, P < 0.001). The cost of investigations recommended by NICE would have been £15,881 greater than existing practice.

CONCLUSION

This study suggests patients attending RACPC will have a greater likelihood of CAD than predicted by NICE. Differences between recommended investigations and existing practice will guide investment in cardiac services. Individual hospitals should assess their RACPC cohorts prior to implementing the NICE guidelines.

The consequences of applying NICE chest pain guidelines to an acute medical population: a role for cardiac computed tomography

BACKGROUND

Cardiac computed tomography (CCT) is a well-validated investigation for the non-invasive assessment of coronary artery disease (CAD). The National Institute for Clinical Excellence (NICE) have recently released guidelines incorporating CCT into the diagnostic algorithm for chest pain of recent onset.

AIM

To assess the frequency of eligibility for CCT in medical admissions with suspected cardiac chest pain using criteria defined by NICE.

DESIGN

A retrospective, observational study, set in a teaching hospital acute medical unit.

METHODS

A total of 198 consecutive patients admitted over a 4-month period with suspected cardiac chest pain (57% male; mean age 63.5 years) were assessed for eligibility for CCT based on NICE guideline criteria.

RESULTS

Of the 198 patients admitted, 65 (33%) patients were excluded by a raised troponin I or ischaemic ECG changes; 100 (51%) patients were excluded by pain categorized as non-anginal and 171 (86%) patients were excluded by a modified Diamond Forrester score outside the range 10-29%. Applying NICE criteria to this population ultimately resulted in 2 (1%) patients recommended for CCT, 12 (6%) for functional cardiac testing and 17 (9%) for invasive angiography.

CONCLUSION

Applying current NICE guidelines for chest pain of recent onset to medical admissions results in a lesser uptake of CCT than functional testing and invasive angiography. If the NICE guidelines are revised to include patients with an intermediate pre-test probability of CAD, CCT may have a greater role.

Inactivation of viruses infecting ectothermic animals by amphibian and piscine antimicrobial peptides

The ability of five purified amphibian antimicrobial peptides (dermaseptin-1, temporin A, magainin I, and II, PGLa), crude peptide fractions isolated from the skin of Rana pipiens and R. catesbeiana, and four antimicrobial peptides (AMPs) from hybrid striped bass (piscidin-1N, -1H, -2, and -3) were examined for their ability to reduce the infectivity of channel catfish virus (CCV) and frog virus 3 (FV3). All compounds, with the exception of magainin I, markedly reduced the infectivity of CCV. In contrast to CCV, FV3 was 2- to 4-fold less sensitive to these agents. Similar to an earlier study employing two other amphibian peptides, the agents used here acted rapidly and over a wide, physiologically relevant, temperature range to reduce virus infectivity. These results extend our previous findings and strongly suggest that various amphibian and piscine AMPs may play important roles in protecting fish and amphibians from pathogenic viruses.

Postmodernism in marriage and family therapy training: doctoral students' understanding and experiences

The purpose of this study is to advance our understanding of how doctoral students perceive postmodernism's influence in the field of Marriage and Family Therapy (MFT). According to the literature, postmodernism has had a profound impact on many fields, including MFT. However, tracking of how postmodernism is actually being rendered in theory, research, practice, and training warrants investigation. This study utilized focus group interviews to investigate the perceptions of MFT doctoral students. Findings suggest that while participants are attracted to postmodern tenets, they also report feeling a mixture of liberation and excitement with confusion and fear regarding how postmodernism is influencing MFT models of therapy.

Evaluation of alternative CD4 technologies for the enumeration of CD4 lymphocytes

Enumeration of CD4+ T cells from persons infected with the human immunodeficiency virus (HIV) is important. Traditionally this measurement has been calculated by multiplying the percent of lymphocytes that are CD4+ T cells (from flow cytometry) and the number of lymphocytes per microliter of blood (from hematology measures). Recently, several manufacturers have developed new techniques for determining absolute numbers of CD4+ and CD8+ cells without the need for the flow cytometer and hematology analyzer. We evaluated these methods for accuracy (comparison with traditional methodology) and precision (variability of replicate determinations) as well as for use with specimens older than 1 day. Precision of the assays as determined by the coefficients of variation (CV) from replicates varied from about 3% to about 12%, depending on the assay and the HIV status of the patient. Correlation coefficients of test method results with the standard methodology (r) were all greater than 0.9, and in most cases slopes were close to 1.0 for both CD4 and CD8. Though each methodology will meet different requirements in the laboratory, our results indicate that these assays are all acceptable for enumerating CD4 and CD8 cells in HIV+ as well as HIV- patients.

Bovine beta-mannosidosis: pathologic and genetic findings in Salers calves

beta-mannosidosis is a recently recognized lysosomal storage disease in newborn Salers calves. Fourteen calves with beta-mannosidase deficiency were examined. Twelve calves were from routine laboratory submissions, and two calves were the result of a breeding trial. Salers calves with beta-mannosidase deficiency were of normal gestational weight, 36 +/- 6 kg, but were affected at birth. The head was moderately domed, and there was mild superior brachygnathism. The calves were recumbent and had a head tremor. There was bilateral renal enlargement, severe hypomyelination in the brain and variable thyroid gland enlargement. Severe cytoplasmic vacuolation was present within neurons, tubule epithelial cells, follicular cells and macrophages of the nervous, renal, thyroid and lymphoid tissues, respectively. Pedigree analysis and breeding trial results were consistent with an autosomal recessive disease. An initial biochemical survey of 1,494 Salers cattle indicated a carrier frequency of 23%.

National survey of clinical and subclinical mastitis in Jamaican dairy herds, 1985-1986

Between April 1985 and August 1986, 89 Jamaican dairy herds with 10 or more cows were visited, 1,645 lactating cows were examined using the CMT test and 254 composite milk samples collected for bacteriological examination. Widespread management faults were noted, especially of milking machine usage and maintenance and the abuse of antibiotics. Fifty-six per cent of all quarters were found to have CMT scores of one or higher, 0.8% showed clinical mastitis and 3.2% were blind. The most common bacterial pathogen Staphylococcus aureus, was recovered from 31% of sampled cows. The resultant milk loss from clinical and subclinical mastitis was estimated to be 20% of the potential national production.

Bovine beta-mannosidase deficiency

A fatal inherited glycoprotein storage disorder is described in Salers cattle which affects both sexes. Affected calves are unable to stand at birth, have a marked intention tremor, markedly enlarged kidneys, decreased white matter in all areas of the brain, and cytoplasmic vacuolation in multiple cell types of multiple tissues with nervous, renal, lymphoid and thyroid tissues most severely affected. Affected calves were grossly deficient in lymphocyte and brain beta-mannosidase activity and had markedly reduced but not deficient activity in liver and kidney. A test mating of obligate carriers produced three genotypes: affected, carrier, non-carrier in essentially the expected ratio of 1:2:1, consistent with autosomal recessive inheritance.

Antibodies to major outer membrane proteins of Escherichia coli in urinary infection in the elderly

The serologic response to infection in elderly bacteriuric subjects and young women with acute pyelonephritis was measured with an enzyme-linked immunosorbent assay (ELISA) using the major outer membrane protein complex (MOMP) of one Escherichia coli strain as antigen. Elderly controls and subjects with asymptomatic bacteriuria had variable titers; control titers were significantly lower than those with asymptomatic bacteriuria. Titers were stable over 2-12 w in asymptomatic subjects. Elderly subjects with invasive infection and women with pyelonephritis demonstrated increases in titer between acute and convalescent serum for E. coli and other Enterobacteriaceae. With a convalescent specimen with an antibody titer greater than or equal to 3 standard deviations (SD) above the acute, the sensitivity of the MOMP ELISA for identifying invasive infection was 74%, the specificity 86%, the positive predictive value 82%, and the negative predictive value 79%. With the criteria of greater than or equal to 3 SD or an initial serum to control ratio of greater than or equal to 15 these parameters were 95%, 82%, 82%, and 95%, respectively. These initial investigations suggest the MOMP of E. coli may be an antigen with wide cross-reactivity, suitable for use as an objective test to identify invasive Enterobacteriaceae urinary infection.

Outcome following antimicrobial therapy for asymptomatic bacteriuria in elderly women resident in an institution

Twenty-six elderly (mean age 83.3 +/- 8.7 years) institutionalized women with asymptomatic bacteriuria were treated with antibiotic therapy, including initial single-dose and subsequent 2 weeks' therapy, then 6 weeks' therapy if relapse occurred. Forty-seven courses of single-dose, 30 of 2 weeks', and 10 of 6 weeks' therapy were given during a 1-year period. At 8 weeks of follow-up, 57% of single-dose courses, 52% of 2-week, and 29% of 6-week had been followed by relapse, and 32%, 24%, and 29%, respectively, by reinfection. Outcome with single-dose therapy did not correlate with infecting organism, antimicrobial therapy, or presence of pyuria with the infection. However, residents who persistently relapsed following single-dose therapy appeared to be a less-well population, as evidenced by a significantly greater age, number of chronic disease diagnoses and medications, as compared to those who were cured by single-dose therapy. Thus, recurrent infection, including both relapse and reinfection is the usual short-term outcome following therapy for asymptomatic bacteriuria in this population. Differences in patient characteristics may prove useful in predicting which individuals may respond to minimal therapy.

Do the beta-hemolytic non-group A streptococci cause pharyngitis?

Implication of the beta-hemolytic non-group A streptococci (BHNAS) as pharyngeal pathogens has been based predominantly on reports of a few outbreaks, small case clusters, and anecdotes. These organisms have long been noted to constitute a significant number of the beta-hemolytic streptococcal isolates from throats of symptomatic and asymptomatic patients in a variety of populations. Laboratory studies have demonstrated the usefulness of anaerobic atmosphere and prolonged incubation in maximizing isolation of the BHNAS. More recently, genetic studies have furthered our appreciation of the taxonomy and have defined two major groups: Streptococcus anginosus-milleri group and large-colony BHNAS; the latter can be further separated on the basis of serogrouping and biotyping. Recognition of this diversity gives justification to the reexamination of the epidemiology and disease course of BHNAS pharyngitis. Treatment studies will also be required if all or subsets of these organisms can be confirmed as pharyngeal pathogens.

Comparison of agar disk diffusion, microdilution broth, and agar dilution for testing antimicrobial susceptibility of coagulase-negative staphylococci

A collection of 120 oxacillin-susceptible and 120 oxacillin-resistant coagulase-negative staphylococci (CNS) from six tertiary care hospital laboratories were tested by agar disk diffusion, three microdilution broth systems (Sensititre, Dynatech, and Alpkem), and the Vitek AutoMicrobic system for comparison with reference agar dilution results. The antimicrobial agents tested were oxacillin, cefazolin, cefotaxime, cefuroxime, cefamandole, fusidic acid, rifampin, and vancomycin. Incubation was at 30 or 35 degrees C for 24, 48, and 72 h. The broth media were supplemented with 2% NaCl for some antimicrobial agents, and the agar dilution method was used with and without the addition of 4% NaCl. The CNS were identified to species by the method of Kloos and Schleifer. The results showed a lack of concordance between two hospitals with respect to oxacillin susceptibility testing by agar dilution with no NaCl supplement. The reasons are not clear but may be related to variations in media. The 4% NaCl supplement or extended incubation to 48 h eliminated this difference. The cefazolin and cefotaxime susceptibility results in the agar disk diffusion test were unreliable if accepted at face value. Cefamandole testing correlated well with the reference method regardless of the method used, and salt supplementation is not recommended. Most of the oxacillin-resistant CNS were resistant to the other beta-lactam drugs except cefamandole. Of 22 CNS resistant to cefamandole, 21 were S. haemolyticus.

Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women

Fifty elderly (mean age, 83.4 +/- 8.8 years) institutionalized women with asymptomatic bacteriuria were randomly assigned either to receive therapy for treatment of all episodes of bacteriuria identified on monthly culture or to receive no therapy unless symptoms developed. Subjects were followed for one year. The therapy group had a mean monthly prevalence of bacteriuria 31 +/- 15 percent lower than those in the no-therapy group, but periods free of bacteriuria lasting six months or longer were documented for only five (24 percent) subjects. For residents receiving no therapy, 71 percent showed persistent infection with the same organism(s). Antimicrobial therapy was associated with an increased incidence of reinfection (1.67 versus 0.87 per patient-year) and adverse antimicrobial drug effects (0.51 versus 0.046 per patient-year) as well as isolation of increasingly resistant organisms in recurrent infection when compared with no therapy. No differences in genitourinary morbidity or mortality were observed between the groups. Thus, despite a lowered prevalence of bacteriuria, no short-term benefits were identified and some harmful effects were observed with treatment of asymptomatic bacteriuria. These data support current recommendations of no therapy for asymptomatic bacteriuria in this population.

Hemoglobin H disease with hemoglobin Constant Spring in a child of Laotian extraction

In alpha-thalassemia, deletion or inactivation of one, two, three, or all four alpha-genes causes, respectively, silent carrier state (-alpha/alpha alpha); alpha-thalassemia trait (--/alpha alpha in Orientals, and -alpha/-alpha in blacks); Hb H disease (--/-alpha); and Hb Bart's hydrops fetalis (--/--). We have described a case of Hb H disease with Hb Constant Spring (--/alpha alpha cs) in a Laotian child whose father had alpha-thalassemia trait and whose mother was a carrier of Hb CS, a mutant hemoglobin produced in minimal amounts. Since alpha-thalassemia is highly prevalent in Southeast Asia, physicians should become alert to the potential occurrence of Hb H disease and Hb Bart's hydrops fetalis in the new Oriental immigrants and their progeny.

Perennial rhinitis. A common childhood complaint

Symptoms of rhinitis in 595 children who attended an allergy clinic over a four-year period were examined to determine the relative frequencies of perennial rhinitis and seasonal rhinitis (hay fever). Perennial rhinitis was much more common than seasonal rhinitis at all ages, and only 12% of children with rhinitis had symptoms restricted to the grass pollen season. The detection of eosinophils in nasal smears from subjects with rhinitis was uncommon (10% of cases), while mast cells were found in one third of cases. Rhinitis was the most common symptom of atopic disease.

Healed Miliary Tuberculosis

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MULTIPLE MYELOMA: REPORT OF CASE

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SECONDARY HYPERTROPHIC OSTEOAR-THROPATHY FOLLOWING METASTATIC SARCOMA OF THE LUNG: REPORT OF A CASE

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