Subclinical tuberculosis and adverse infant outcomes in pregnant women with HIV

BACKGROUND: Tuberculosis (TB) in pregnant women with HIV is associated with adverse maternal and infant outcomes. Previous studies have described a substantial prevalence of subclinical TB in this group, but little is known about the impact of subclinical TB on maternal and pediatric outcomes.METHODS: The Tshepiso Study recruited 235 HIV-infected pregnant women with TB (and matched HIV-positive, TB-negative pregnant controls), in Soweto, South Africa, from 2011 to 2014. During enrolment screening, some women initially recruited as controls were subsequently diagnosed with prevalent TB. We therefore assessed the prevalence of subclinical TB, associated participant characteristics and outcomes.RESULTS: Of 162 women initially recruited as TB-negative controls, seven (4.3%) were found to have TB on sputum culture. All seven had negative WHO symptom screens, and six (86%) were smear-negative. Of their seven infants, one was diagnosed with TB, and three (43%) experienced complications compared to zero infants with TB and 11% experiencing complications in the control group of TB-negative mothers (P = 0.045).CONCLUSION: We discovered an appreciable prevalence of subclinical TB in HIV-infected pregnant women in Soweto, which had not been detected by screening algorithms based solely on symptoms. Infants of HIV-infected mothers with subclinical TB appear to have a higher risk of adverse outcomes than those of TB-negative mothers.

Donor understandings of blood and the body in relation to more frequent donation

BACKGROUND AND OBJECTIVES

The INTERVAL trial aimed to find the optimum frequency of blood donation to enhance blood supplies and maintain donor health. This not only requires biological knowledge, but also an appreciation of donor perspectives, and how their experiences and beliefs might be central if any changes are ever to be made. To address this, trial participants were interviewed about their ideas of blood and the body in relation to their experiences of increased donation frequency.

MATERIALS AND METHODS

Thirty in depth face-to-face interviews conducted with blood donors participating in the trial.

RESULTS

Three key themes emerged: ideas about how blood and iron reserves are replenished, and what people did to facilitate this; beliefs about physiological differences relating to age and gender; and practical issues that affected the experience of donation. Overall, participants interviewed welcomed more frequent donation, despite a range of pragmatic concerns.

CONCLUSION

Despite some practical obstacles, increased donation frequency aligned with participant's ideas about bodily replenishment, the value of donation, and their identity as enduring blood donors. They therefore supported the idea of increasing frequency of donation, independently of the biomedical evidence from the trial itself.

Cooking-related PM2.5 and acrolein measured in grocery stores and comparison with other retail types

We measured particulate matter (PM), acrolein, and other indoor air contaminants in eight visits to grocery stores in California. Retail stores of other types (hardware, furniture, and apparel) were also sampled on additional visits. Based on tracer gas decay data, most stores had adequate ventilation according to minimum ventilation rate standards. Grocery stores had significantly higher concentrations of acrolein, fine and ultrafine PM, compared to other retail stores, likely attributable to cooking. Indoor concentrations of PM2.5 and acrolein exceeded health guidelines in all tested grocery stores. Acrolein emission rates to indoors in grocery stores had a mean estimate about 30 times higher than in other retail store types. About 80% of the indoor PM2.5 measured in grocery stores was emitted indoors, compared to only 20% for the other retail store types. Calculations suggest a substantial increase in outdoor air ventilation rate by a factor of three from current level is needed to reduce indoor acrolein concentrations. Alternatively, acrolein emission to indoors needs to be reduced 70% by better capturing of cooking exhaust. To maintain indoor PM2.5 below the California annual ambient standard of 12 μg/m(3) , grocery stores need to use air filters with an efficiency rating higher than the MERV 8 air filters commonly used today.

Cost-effectiveness of tuberculosis screening and isoniazid treatment in the TB/HIV in Rio (THRio) Study

OBJECTIVE

To estimate the incremental cost-effectiveness of tuberculosis (TB) screening and isoniazid preventive therapy (IPT) among human immunodeficiency virus (HIV) infected adults in Rio de Janeiro, Brazil.

DESIGN

We used decision analysis, populated by data from a cluster-randomized trial, to project the costs (in 2010 USD) and effectiveness (in disability-adjusted life years [DALYs] averted) of training health care workers to implement the tuberculin skin test (TST), followed by IPT for TST-positive patients with no evidence of active TB. This intervention was compared to a baseline of usual care. We used time horizons of 1 year for the intervention and 20 years for disease outcomes, with all future DALYs and medical costs discounted at 3% per year.

RESULTS

Providing this intervention to 100 people would avert 1.14 discounted DALYs (1.57 undiscounted DALYs). The median estimated incremental cost-effectiveness ratio was $2273 (IQR $1779-$3135) per DALY averted, less than Brazil's 2010 per capita gross domestic product (GDP) of $11,700. Results were most sensitive to the cost of providing the training.

CONCLUSION

Training health care workers to screen HIV-infected adults with TST and provide IPT to those with latent tuberculous infection can be considered cost-effective relative to the Brazilian GDP per capita.

Contaminant levels, source strengths, and ventilation rates in California retail stores

This field study measured ventilation rates and indoor air quality in 21 visits to retail stores in California. Three types of stores, such as grocery, furniture/hardware stores, and apparel, were sampled. Ventilation rates measured using a tracer gas decay method exceeded the minimum requirement of California's Title 24 Standard in all but one store. Concentrations of volatile organic compounds (VOCs), ozone, and carbon dioxide measured indoors and outdoors were analyzed. Even though there was adequate ventilation according to standard, concentrations of formaldehyde and acetaldehyde exceeded the most stringent chronic health guidelines in many of the sampled stores. The whole-building emission rates of VOCs were estimated from the measured ventilation rates and the concentrations measured indoor and outdoor. Estimated formaldehyde emission rates suggest that retail stores would need to ventilate at levels far exceeding the current Title 24 requirement to lower indoor concentrations below California's stringent formaldehyde reference level. Given the high costs of providing ventilation, effective source control is an attractive alternative.

PRACTICAL IMPLICATIONS

Field measurements suggest that California retail stores were well ventilated relative to the minimum ventilation rate requirement specified in the Building Energy Efficiency Standards Title 24. Concentrations of formaldehyde found in retail stores were low relative to levels found in homes but exceeded the most stringent chronic health guideline. Looking ahead, California is mandating zero energy commercial buildings by 2030. To reduce the energy use from building ventilation while maintaining or even lowering formaldehyde in retail stores, effective formaldehyde source control measures are vitally important.

The effects of an energy efficiency retrofit on indoor air quality

To investigate the impacts of an energy efficiency retrofit, indoor air quality and resident health were evaluated at a low-income senior housing apartment complex in Phoenix, Arizona, before and after a green energy building renovation. Indoor and outdoor air quality sampling was carried out simultaneously with a questionnaire to characterize personal habits and general health of residents. Measured indoor formaldehyde levels before the building retrofit routinely exceeded reference exposure limits, but in the long-term follow-up sampling, indoor formaldehyde decreased for the entire study population by a statistically significant margin. Indoor PM levels were dominated by fine particles and showed a statistically significant decrease in the long-term follow-up sampling within certain resident subpopulations (i.e. residents who report smoking and residents who had lived longer at the apartment complex).

Do Not Attempt Cardiopulmonary Resuscitation orders in acute medical settings: a qualitative study

BACKGROUND

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders have been shown to be independently associated with patients receiving fewer treatments, reduced admission to intensive care and worse outcomes even after accounting for known confounders. The mechanisms by which they influence practice have not previously been studied.

OBJECTIVES

To present a rich qualitative description of the use of the DNACPR form in a hospital ward setting and explore what influence it has on the everyday care of patients.

DESIGN

Multi-source qualitative study, primarily using direct observation and semi-structured interviews based on two acute wards in a typical middle-sized National Health Service hospital in UK.

RESULTS

The study identified a range of ways in which DNACPR orders influence ward practice, beyond dictating whether or not cardiopulmonary resuscitation should be attempted. Five key themes encapsulate the range of potential impacts emerging from the data: the specific design and primacy of the form, matters relating to clinical decision making, staff reflections on how the form can affect care, staff concern over 'inappropriate' resuscitation, and discussions with patients/relatives about DNACPR decisions. Overall, it was found that while the DNACPR form is recognized as serving a useful purpose, its influence negatively permeated many aspects of clinical practice.

CONCLUSION

DNACPR orders can act as unofficial 'stop' signs and can often signify the inappropriate end to clinical decision making and proactive care. Many clinicians were uncomfortable discussing DNACPR orders with patients and families. These findings help understand why patients with DNACPR orders have worse outcomes, as such they may inform improvements in resuscitation policies.

Quality of life among people treated for tuberculosis and human immunodeficiency virus in Rio de Janeiro, Brazil

We measured quality of life (QOL) among individuals receiving treatment for human immunodeficiency virus (HIV; n = 45), active tuberculosis (TB; n = 44) and both TB and HIV (n = 9) in Rio de Janeiro, Brazil. Active treated TB was associated with lower physical health (absolute decrease of 0.95 standard deviation in summary score), but not mental health, among people being treated for HIV. Visual analogue scale scores were similar across all three populations, and corresponded closely to standard disability weights used in the literature. Among patients receiving treatment, those with HIV, active TB and both conditions together appear to have similar QOL.

Developing a programme for healthy growth and nutrition during infancy: understanding user perspectives

BACKGROUND

Avoiding excess energy intake and rapid weight gain during infancy may be effective in preventing childhood obesity. We developed a programme for healthy growth and nutrition in formula milk-fed babies. The aim of this study was to understand users' perspectives about the programme and planned trial.

METHODS

We conducted three focus group discussions (10 mothers) and nine individual interviews (seven health visitors, one midwife and one mother) discussing the programme materials and trial protocol. All sessions were transcribed verbatim and a thematic analysis was performed using the framework approach.

RESULTS

Mothers reported receiving conflicting messages about infant feeding and were keen for consistent advice. They welcomed the support that the programme would offer to mothers who gave their babies formula milk, but some were sceptical about the feasibility of limiting formula milk quantities. They suggested that recommended quantities should be presented as general guidelines rather than rigid rules. Some mothers said that it was too early to intervene to prevent obesity, that babies could not be overfed and that the risks of formula milk feeding had been exaggerated. Because of the routine advice to feed on demand, babies were fed in response to crying, and crying was equated with 'hunger'. Some mothers said that growth was genetically determined so they ignored the growth charts. Health visitors used the growth charts to assess adequate weight gain rather than to identify excess weight gain. Health visitors said that mothers would need a lot of education and support to limit formula milk quantities.

CONCLUSIONS

Efforts to prevent childhood obesity by avoiding excess weight gain during infancy have to address mothers' beliefs that babies cannot be overfed, that crying always signals hunger and that growth is determined by genes rather than nutrition. Mothers and healthcare providers have different motivations and understanding these are important in the development of any intervention.

A phase III trial of biologically-based therapy reduction for intermediate risk neuroblastoma

9504

Background: Infants with advanced neuroblastoma (stage 3 and 4) and children >1 year with favorable biology stage 3 disease have had a survival exceeding 80% with aggressive chemotherapy. The primary objective of Childrens Oncology Group A3961 was to maintain a 3-year event-free and overall survival rate above 90% for intermediate risk (IR) neuroblastoma with a reduction in therapy compared to historical trials for similarly defined risk patients. Methods: IR patients were defined by selected clinical (age, INSS stage, histopathology) and biologic (MYCN status and DNA index) factors. All eligible IR patients were MYCN non-amplified and were divided into subcategories defined as favorable or unfavorable biology. Therapy consisted of 2 to 3 agent combinations of carboplatin, etoposide, cyclophosphamide and doxorubicin given every 3 weeks for a total of 4 cycles (favorable biology) or 8 cycles (unfavorable biology). Patients with favorable biology failing to achieve CR/VGPR after 4 cycles and surgery, received 8 cycles. All patients were required to enter a companion neuroblastoma biology study and to enroll on A3961 within 28 days of diagnosis. Results: Between March 1997 and May 2005, 467 eligible patients were enrolled on study. These included 261 stage 3 (105 children; 156 infants), 174 stage 4 infants, and 32 stage 4s infants. 362 (78%) were less than 12 months of age at diagnosis. 330 (71%) patients had favorable and 137 (29%) unfavorable biology. There were 40 (12.1%) of 330 favorable biology patients who went onto cycles 5–8. There were 52 events in 467 cases including 15 deaths and two secondary AML. Conclusions: The primary hypothesis of this study was confirmed and survival rates greater than 90% were maintained for IR neuroblastoma with reduced therapy compared to historical trials. The successor trial will prescribe duration of therapy based, in part, on loss of heterozygosity states at 1p36 and 11q23 as well as initial response to treatment in an endeavor to further reduce therapy for this group of patients.

[Table: see text]

No significant financial relationships to disclose.

Over-expression of the A3 adenosine receptor in tumor and PBMC of hepatocellular carcinoma patients: A specific therapeutic target

14085

Background: The Gi protein associated A3 adenosine receptor (A3AR) is highly expressed in colon carcinoma tissue and is reflected in peripheral blood mononuclear cells (PBMC) of the patients. Drug candidates with high affinity to the receptor possess anti-cancer effect when administered orally to colon carcinoma bearing animals. The receptor was suggested as a potent therapeutic target and predictive biological marker. Since there is no adequate therapy for Hepatocellular Carcinoma (HCC) we looked at the presence of A3AR in tumor and PBMC of HCC patients and tested the efficacy of the A3AR agonist, CF102 in an experimental rat HCC model. Methods: mRNA and protein A3AR expression level were examined in paraffin embedded slides and PBMC from HCC patients utilizing RT-PCR and Western blot (WB) analysis, respectively. Rat HCC model was established by inoculating N1S1 cells to the animals’ liver. Oral treatment with CF102 was initiated 5 days after tumor inoculation. Signaling proteins in tumor lesions and PBMC from the animals was tested by WB analysis. Results: A3AR over-expression was found in tumor and PBMC of HCC patients. Receptor over-expression was attributed to high expression of NF-κB, known to act as a transcription factor of A3AR. In the HCC bearing rats, A3AR was over-expressed in the tumor tissue and PBMC. Upon treatment with CF102 A3AR expression was down-regulated followed by inhibition of tumor size (60%±18.4%, p<0.05). Mechanistically, CF102 de-regulated the NF-κB and Wnt signaling pathways. Conclusions: A3AR which is up- regulated in HCC tumors may be suggested as a new target to treat this malignancy and as a biological marker to follow up tumor response to the drug.

No significant financial relationships to disclose.

Experiences and expectations of refugee doctors: Qualitative study

BACKGROUND

Refugee doctors constitute a potentially valuable resource for reducing the recruitment crisis in psychiatry. However, various hurdles make their route into the National Health Service (NHS) difficult.

AIMS

To explore the perceptions and experiences of refugee doctors trying to practise psychiatry in the UK.

METHOD

Thirty-one refugee doctors participated in qualitative interviews designed to elicit their experiences in trying to practise as doctors in the UK. Twenty were re-interviewed about 6 months later.

RESULTS

Doctors identified a range of practical problems that made it difficult for them to take the required steps towards practising in the UK. These included lack of appropriate information, lack of a clear route through the system and feelings of isolation. The English language examination was seen as a particular bottleneck, as were finding clinical attachments. The psychological impact of the experience was profound.

CONCLUSIONS

These findings have important implications for how refugee doctors are introduced to the practice of psychiatry in the NHS.

A3 adenosine receptor is highly expressed in hepatocellular carcinoma: A new therapeutic target

13164

Background: The A3 adenosine receptor (A3AR) belongs to the family of the Gi-protein associated receptors and is highly expressed in various solid tumor tissues. The high receptor expression is reflected also in the peripheral blood mononuclear cells (PBMNC) of the cancer patients. Synthetic agonists to A3AR such as IB-MECA and Cl-IB-MECA (CF101 and CF102, respectively) suppress the development of melanoma, colon and prostate carcinoma in vitro and in vivo. The molecular mechanism involves de-regulation of the Wnt and the NF-kB signal transduction pathways. In this study we looked at A3AR expression in tumor and PBMNC of hepatocellular carcinoma (HCC) patients. In addition, receptor status model and the effect of CF102 on tumor development were examined in an HCC rat. Methods: A3AR mRNA expression level was examined in paraffin embedded slides derived from human HCC samples. A3AR protein expression was evaluated in human PBMNC by Western blot (WB) analysis. Rat HCC was established by inoculating N1S1 cells to the liver. Oral treatment with CF102, administered BID, was initiated 24h after tumor inoculation. A3AR and key growth regulatory proteins expression level in tumor lesions and PBMNC was tested by WB analysis. Results: A3AR was found to be highly expressed in the human HCC tumor tissue and the PBMNC compared to normal adjacent and PBMNC from healthy subjects, respectively. Similar data were found in tumor and PBMNC derived from N1S1 hepatoma bearing rats. In tumor lesions from CF102 treated animals, down-regulation of PKB/Akt, IKK, NF-κB and TNF-α, members of the NF-kB pathway was noted. In addition de-regulation of the Wnt pathway was observed by up-regulation of GSK-3β and down-regulation of β-catenin, Lef/Tcf and c-Myc, resulting in tumor growth inhibition. Conclusion: CF102, a small orally bioavailable molecule, binds to the A3AR which is highly expressed on tumor cells and via the de-regulation of the NF-kB and Wnt pathway induces inhibition of HCC growth.

No significant financial relationships to disclose.

Where do adolescents get their condoms?

PURPOSE

To determine where adolescents obtain their condoms; the availability and accessibility of condoms; condom availability in relationship to different sexually transmitted disease (STD) rates; and the availability of safer sex information in places where condoms are sold.

METHODS

We conducted a random digit-dialed telephone survey of 259 14-19-year-old adolescents in Monroe County, New York. Self-reported health services use, knowledge and use of confidential services, and where adolescents obtained or intended to obtain condoms were assessed. Research assistants visited all retail establishments in five areas of similar population size with gonorrhea rates from 887 to 12,427 per 100,000 adolescents to assess how available and accessible condoms were in each store. Perceived access and actual condom availability and accessibility were compared using Chi-square and Student's t-tests.

RESULTS

Trained interviewers dialed 11,800 numbers in 1993, identifying 4449 (40%) households among 11,065 numbers reached successfully. Of these, 393 (8.8%) had eligible adolescents and 259 (66%) completed interviews. Most adolescents reported obtaining, or planning to obtain, condoms in stores rather than from free health care settings. Adolescents who have used condoms more often reported having obtained them without cost than having purchased them. Condoms were available at 101 (83%) of 122 stores identified. All drug stores and 75% of supermarkets sold condoms and displayed them openly. Most small grocery stores also sold condoms (92%), but were less likely to openly display them. No stores displayed or provided safer sex information. Areas with higher STD rates had more stores (p <.01), and more stores that sold condoms (p <.01). There was no difference in condom cost by area.

CONCLUSIONS

Many adolescents obtain their condoms in retail stores. Condom accessibility varied by store type and area STD rate. Increasing condom visibility in private grocery stores may increase the accessibility of condoms to adolescents in areas with highest STD rates.

Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomized, prospective trial

BACKGROUND

Critically ill trauma patients frequently require prolonged endotracheal intubation and ventilator support. After extubation, swallowing difficulties may exist in < or = 50% of patients. We sought to determine whether performing a swallowing evaluation would reduce the incidence of postextubation aspiration and subsequent pneumonia.

DESIGN

Randomized, prospective clinical trial of fiberoptic endoscopic evaluation of swallowing (FEES) vs. routine clinical management in patients after prolonged intubation.

METHODS

Seventy patients who were intubated for > 48 hrs were randomized. FEES examinations were performed within 24 +/- 2 hrs after extubation. Silent aspiration was defined as the appearance of liquid or puree bolus below the true vocal cords without coughing during a FEES examination. Clinical aspiration was defined as the removal of enteral content from below the vocal cords, usually during endotracheal tube placement.

RESULTS

There were five episodes of aspiration and pneumonia in the FEES group (14%, two silent) and two in the clinical group (6%, not significant, Fisher exact test). Patients aged > 55 yrs and those with vallecular stasis on FEES examination were at significantly higher risk of postextubation aspiration. All patients with pneumonia had an associated aspiration episode.

CONCLUSIONS

Patients with prolonged orotracheal intubation are at risk of aspiration after extubation. The addition of a FEES examination did not change the incidence of aspiration or postextubation pneumonia.

Comparison of antral tap with endoscopically directed nasal culture

OBJECTIVES/HYPOTHESIS

The diagnosis of acute bacterial rhinosinusitis continues to generate controversy in critically ill patients. The efficacy of endoscopically directed cultures in these patients is unknown. We compared antral tap (AT) with endoscopic tissue culture (ETC) of the osteomeatal complex in an intensive care unit (ICU) setting.

METHODS

Twenty patients admitted to a surgical/trauma ICU were evaluated by AT and ENB for the presence of rhinosinusitis. All patients had 1) a fever of unknown origin without resolution on empiric antibiotic therapy for > or =48 hrs; 2) other sources of fever ruled out; 3) computed tomography scan evidence of mucoperiosteal thickening +/- sinus air/fluid levels; and 4) attempt at conservative treatment with topical decongestants and removal of all nasal intubation. Microbiologic data were collected and analyzed for any statistical difference between groups.

RESULTS

A total of 29 sides underwent simultaneous tap and endoscopically directed tissue culture. The mean age was 40 years (range, 23-77 y) with 85% being males. Fifteen of 20 (75%) patients in the AT group were culture-positive. Of the 49 isolates from the AT, 55% yielded Gram-negative bacilli (Acinetobacter sp. 37%) and 45% yielded Gram-positive cocci. The ETC group was culture-positive in 18 of 20 (90%) patients. Of the 52 isolates from the ETC, Gram-negative bacilli were found in 58% (Acinetobacter sp. 33%) and 42% yielded Gram-positive cocci. The ETCs were culture-positive in all but 1 patient with positive taps. There appeared to be a concordance between AT and ETC in 60% of the patients. In five instances (25%), results of the AT or ETC changed ICU management. Two patients ultimately required sinus surgery.

CONCLUSIONS

Sinus taps and/or endoscopically directed tissue cultures led to a change in ICU care in 25% of ICU patients studied. In patients with fever of unknown origin and computed tomography evidence of sinusitis, an antral tap continues to provide important information concerning maxillary sinusitis. However, ETC may give as good a representation of the microbiology and secondary inflammatory changes responsible for bacterial ICU rhinosinusitis causing fever of unknown origin. Further study on a larger group of patients is needed.

Dynamics of behavioral risk factors for HIV/AIDS: a 6-year prospective study of injection drug users

This prospective study of 2960 injection drug users investigated the dynamic nature of HIV behavioral risk factors between 1988 and 1994. Behavioral risks were assessed semi-annually. Robust regression models of time-dependent covariates were used to identify longitudinal predictors of behavior change. Maintenance of risky behaviors varied over time, with risk reduction seen more among HIV infected participants than among HIV seronegatives. Those at highest risk for HIV transmission were least likely to cease engaging in these behaviors. Interventions staged according to risk behaviors, targeting incremental risk reduction rather than only promoting abstinence, may be more successful in reducing HIV transmission among drug injectors.

Lipopolysaccharide is radioprotective in the mouse intestine through a prostaglandin-mediated mechanism

BACKGROUND & AIMS

The bone marrow and the intestine are the major sites of radiation-induced injury. The cellular response to radiation injury in the intestine or bone marrow can be modulated by agents given before irradiation. Lipopolysaccharide is known to be radioprotective in the bone marrow, but its effect on the intestine is not known. We sought to determine if lipopolysaccharide is radioprotective in the intestine and, if so, to determine the mechanism of its radioprotective effects.

METHODS

Mice were treated with parenteral lipopolysaccharide or vehicle and then irradiated (14 Gy total body irradiation in a cesium irradiator). The number of surviving intestinal crypts was assessed 3.5 days after irradiation using a clonogenic assay.

RESULTS

Parenteral administration of lipopolysaccharide 2-24 hours before irradiation resulted in a 2-fold increase in the number of surviving crypts 3.5 days after irradiation. The radioprotective effects of lipopolysaccharide could be eliminated by coadministration of a selective inhibitor of cyclooxygenase 2. Lipopolysaccharide was radioprotective in wild-type mice but not in mice with a disrupted cyclooxygenase 2. Parenteral administration of lipopolysaccharide resulted in increased production of prostaglandins in the intestine and in the induction of cyclooxygenase 2 expression in subepithelial fibroblasts and in villous, but not crypt, epithelial cells.

CONCLUSIONS

Lipopolysaccharide is radioprotective in the mouse intestine through a prostaglandin-dependent pathway.

Technology enhanced learning for occupational and environmental health nursing: a global imperative

One strategy for decreasing the barriers to higher education and for increasing the competency and performance of the occupational and environmental health nurse in the information age is technology enhanced learning. Technology enhanced learning encompasses a variety of technologies employed in teaching and learning activities of presentation, interaction, and transmission to on campus and distant students. Web based learning is growing faster than any other instructional technology, offering students convenience and a wealth of information.

Characterization of kappa1-opioid receptor binding in human insular cortex

Mesolimbic dopaminergic neurotransmission is modulated by dynorphin peptides binding to kappa-opioid receptors. The interaction between dynorphin and dopamine systems makes the kappa-opioid receptor a potential drug discovery target for the development of therapeutic agents for schizophrenia and drug abuse. This study reports the specificity and parameters of [3H]U69593 binding in the insular cortex, a representative corticolimbic area of the human brain. The results demonstrate that the radioligand [3H]U69593 labels a single population of receptors in human insular cortex with an affinity in the low nanomolar range. The pharmacological profile for inhibition of [3H]U69593 binding was determined in this brain region using drugs known to bind to mu, kappa and delta opioid receptors. The results show that kappa-opioid selective agonists and antagonists inhibit binding of this ligand in human brain with comparable affinities and rank order as previously described for rat and guinea pig brain and the cloned kappa1-opioid receptor subtype.

Intravenous and oral mono- or combination-therapy in the treatment of severe infections: ciprofloxacin versus standard antibiotic therapy. Ciprofloxacin Study Group

Five hundred and forty patients with severe infection were enrolled in a multicentre, prospective, randomized, non-blinded study to compare the efficacy and safety of i.v. ciprofloxacin with i.v. standard therapy. Five hundred and thirty-one patients received at least one dose of study drug for pneumonia (310), septicaemia (112) or skin and skin structure infection (109). Intravenous ciprofloxacin (400 mg, every 8 h) or i.v. ciprofloxacin (400 mg, every 8 h) plus a beta-lactam were compared with a standard monotherapy (beta-lactam) or combination (aminoglycoside plus a beta-lactam) therapy. Patients were treated parenterally for a minimum of 2 or 3 days, then at the discretion of the investigator could be switched to oral therapy (ciprofloxacin 750 mg, every 12 h or a standard oral therapy). Patients were randomized in the ratio of 2:1 for the ciprofloxacin and standard therapy treatment groups and stratified to monotherapy if the APACHE II score was < or = 20 or to combination therapy if the APACHE II score was 21-29. Three hundred and ninety-five (74%) patients were valid for the efficacy analysis: these comprised 242 pneumonia (167 ciprofloxacin and 75 standard therapy), 70 septicaemia (47 ciprofloxacin and 23 standard therapy), and 83 skin infections (56 ciprofloxacin and 27 standard). The primary efficacy variable was clinical response and the secondary efficacy assessment was bacteriological response at the end of therapy (2 or 3 days after treatment). The mean duration of therapy for patients receiving only i.v. monotherapy or combination therapy was shorter (9-10 days) than for patients receiving sequential i.v./p.o. therapy (14-17 days). At the end of therapy, overall clinical resolution/improvement (success) for monotherapy was 138/166 (83%) for the ciprofloxacin group, compared with 74/87 (85%) for standard-treated patients (95% CI = -11.5% to 7.6%), and for combination therapy the response was 43/51 (84%) for the ciprofloxacin group and 14/20 (70%) for standard-treated patients (95% CI = -6.3% to 34.9%). For pneumonia, the most frequent infection treated, clinical success rates following monotherapy were 85% for ciprofloxacin and 83% for standard-treated patients and 83% for ciprofloxacin compared with 69% for standard-treated patients in the combination therapy group. Bacteriological eradication/presumed eradication following monotherapy was 85/102 (83%) for ciprofloxacin and 31/46 (67%) for standard-treated patients (95% CI = 1.6% to 30.3%), and that for combination therapy was 29/36 (81%) for ciprofloxacin and 7/10 (70%) for standard-treated patients (95% CI = -18.3% to 39.5%). Drug-related adverse events, primarily diarrhoea and nausea, were reported in 22% of ciprofloxacin-treated patients and 20% of standard-treated patients. In summary, ciprofloxacin administered alone or in combination was found to be effective in treating a wide range of severe infections.

Persistence of viremia and the importance of long-term follow-up after acute hepatitis C infection

The purpose of this investigation was to prospectively characterize acute hepatitis C virus (HCV) infections and to evaluate the hypothesis that the outcome is affected by identifiable clinical or viral factors. One hundred forty-two people with a history of illicit drug use who were HCV antibody-negative in 1988 were followed semiannually through 1996. HCV seroconversion (second generation enzyme immunoassay and recombinant immunoblot assay) was recognized in 43 (30%) of the participants, who were followed up for a median of 72 months. HCV RNA was detected and quantified by polymerase chain reaction in a median of 10 specimens per participant and showed two distinct patterns of viremia: viral clearance was noted in 6 (14%) of the participants, and viral persistence was observed in 37 (86%) of the participants. Subjects with viral clearance were more likely to be white (P =.004), have jaundice (P =.03), and have lower peak viral titer (P =.003). However, the outcome for a given person could not be predicted by clinical features, RNA level, or HCV subtype (as ascertained by analysis of core-E1 complementary DNA sequence). No acute infections were recognized by health care providers. At the time of seroconversion, HCV RNA was detectable in 81% of participants, and recombinant immunoblot assay (RIBA) was positive in 85% of participants. We conclude that approximately 85% of people with acute hepatitis C develop persistent viremia. However, acute infections are uncommonly recognized clinically, underscoring the importance of screening individuals at risk. Long-term follow-up, but no single laboratory test, is necessary to ascertain the outcome and in some cases make the diagnosis of acute HCV infection.

Organ failure, infection, and the systemic inflammatory response syndrome are associated with elevated levels of urinary intestinal fatty acid binding protein: study of 100 consecutive patients in a surgical intensive care unit

BACKGROUND

Intestinal mucosal ischemia and subsequent barrier dysfunction have been related to the development of organ dysfunction and death in the critically ill. We hypothesized that urine concentrations of intestinal fatty acid binding protein (IFABP), a sensitive marker of intestinal ischemia, might predict the development of the systemic inflammatory response syndrome (SIRS) and organ dysfunction.

METHODS

One hundred consecutive critically ill patients were prospectively studied for the development of infectious complications, organ dysfunction, and SIRS. Urine was collected daily for measurement of IFABP.

RESULTS

A total of 58 males and 42 females (mean age, 56 years; range,16-85 years) were studied. Of these 100 patients, 40 patients developed complications and 5 patients developed SIRS. IFABP was significantly elevated in all patients with SIRS, and IFABP levels peaked an average of 1.4 days (range, 0-7 days) before the diagnosis of SIRS.

CONCLUSION

Elevated concentrations of urine IFABP correlated with the clinical development of SIRS. Studies to assess the utility of IFABP as a predictor of organ dysfunction and SIRS in the critically ill are warranted.

Efficacy of autologous peripheral blood stem cell (PBSC) harvest and engraftment after ablative chemotherapy in pediatric patients

Thirty-five pediatric patients, 1-16 years of age (median 6.3 years), with neoplastic solid tumors (n=32) or acute leukemia (n=3) underwent peripheral blood stem cell (PBSC) harvest and transplantation at Children's Memorial Hospital between September 1992 and April 1997. A median of four phereses were performed on each patient. Blood samples from 34 of the 35 patients were harvested through existing double-lumen central catheters, using either a Fenwal CS-3000 or COBE Spectra pheresis machine. The pheresis procedures were well tolerated overall. A median of 3.7 x 10(6)/kg CD34+ cells were infused (range, 0.2-15.5 x 10(6)/kg), and all patients engrafted. The median time to an absolute neutrophil count >500/microL was 13 days (range, 9-44 days) and to a platelet count >20,000/microL was 21 days (range, 9-210 days). Two patients died from transplant-related complications. Patients were discharged from the hospital after a median of 22 days (range, 15-64 days). Twenty of the 35 patients are alive, 17 of whom remain disease-free with a median follow-up of 1144 days. According to this study, PBSCs can be successfully harvested and re-infused for marrow reconstitution after myeloablative therapy in children for a variety of pediatric malignancies with low morbidity and mortality.

Self-reported antiretroviral therapy in injection drug users

CONTEXT

The US Public Health Service and the International AIDS Society-USA recently published recommendations for antiretroviral therapy (ART) for persons infected with human immunodeficiency virus (HIV); however, anecdotal evidence suggests that HIV-infected injection drug users (IDUs) may not be receiving optimal care as defined by the recommendations.

OBJECTIVE

To assess ART use in HIV-infected IDUs.

DESIGN

A cross-sectional survey of self-reported ART use between July 1996 and June 1997 in IDUs.

SETTING

A community-based clinic affiliated with Johns Hopkins University, Baltimore, Md.

PARTICIPANTS

A total of 404 HIV-infected IDUs with CD4+ cell counts less than 0.50 x 10(9)/L recruited into a longitudinal study in 1988 and 1989.

MAIN OUTCOME MEASURE

Self-reported ART use was assessed: no current therapy, monotherapy, or combination therapy with or without a protease inhibitor.

RESULTS

One half (199/404 [49%]) of patients reported no recent ART. A total of 14% (58/404) had monotherapy, 23% (90/404) were receiving combination therapy without a protease inhibitor, and 14% (57/404) had triple-combination therapy with a protease inhibitor. A multivariate analysis of factors associated with ART showed that care continuity and recent HIV-related outpatient visit (odds ratio [OR], 4.30; 95% confidence interval [CI], 2.36-7.81 and OR, 2.84; 95% CI, 1.66-4.88, respectively), CD4+ cell count of less than 0.20 x 10(9) (OR, 2.41; 95% CI, 1.51-3.84), no current drug use and being in drug treatment (OR, 2.16; 95% CI, 1.34-3.47; OR, 2.12; 95% CI, 1.23-3.66, respectively), and unemployment (OR, 2.31; 95% CI, 1.21-4.40) were associated with reporting ART use. In other analysis, less likely to receive protease inhibitors were current drug injectors (OR, 0.5; 95% CI, 0.3-1.0) and those recently incarcerated (OR, 0.2; 95% CI, 0.03-0.9), but patients with acquired immunodeficiency syndrome were more likely to receive protease inhibitors (OR, 2.0; 95% CI, 0.9-4.6). Protease inhibitor use doubled (P<.01) from July and December 1996 to January and June 1997 (7.7% and 14.8%, respectively).

CONCLUSIONS

Those IDUs infected with HIV who were not receiving ART tended to be active drug users without clinical disease who have less contact with health care providers. Although we do not have information on clinical judgment regarding treatment decisions or whether persons were prescribed therapy not taken, the proportion of subjects reporting receiving ART suggests that strategies for improving treatment in this population are indicated. Expanding simultaneous treatment services for HIV infection and substance abuse would enhance the response to these related epidemics.

Computed tomography in the initial evaluation of hemodynamically stable patients with blunt abdominal trauma: impact of severity of injury scale and technical factors on efficacy

BACKGROUND

Although computed tomography is used widely in evaluating injuries from blunt abdominal trauma, grading of injuries does not reliably predict the need for intervention. Objective reporting is essential to evaluate accuracy and facilitate patient triage. We established and tested a five-point grading system for overall severity of injury.

METHODS

A total of 392 computed tomographic trauma cases were objectively classified according to the type and severity of abdominal injuries, by two experienced radiologists. Interobserver variability between the original interpretation and the consensus of the film reviewers was evaluated. The computed tomographic grading system was measured against rate of admission, exploratory laparotomy, and further imaging.

RESULTS

Patients with higher grades of injury on computed tomography were increasingly likely to have surgical management (odds ratio, 3.99; 95% confidence interval, 1.86-8.58; p < 0.0006), with sensitivity 100%, specificity 89.5% for level 2 injuries and higher. Although there was almost perfect agreement between the official interpretation and the reviewers' blinded consensus interpretation (raw agreement 84%, weighted kappa 0.86), indeterminate studies were reduced from 23% (16 of 67) to 12% (8 of 67) on review: these were more likely to have metallic or motion artifacts (5 of 16 vs. 1 of 51 p < 0.002).

CONCLUSIONS

Standardizing reporting of injuries enhances accuracy, and grading eliminates equivocation. Diagnostic certainty in computed tomography of blunt abdominal trauma is reduced by motion and metallic artifacts.

Vitamin A supplementation and human immunodeficiency virus load in injection drug users

The use of vitamin A therapy during human immunodeficiency virus (HIV) infection is under clinical investigation, and vitamin A could potentially modulate HIV replication because the virus genome contains a retinoic acid response element. A randomized, double-masked, placebo-controlled clinical trial was conducted to determine the impact of single high-dose vitamin A supplementation, 60-mg retinol equivalent (200,000 IU), on HIV load and CD4 lymphocyte count. HIV-infected injection drug users (120) were randomly allocated to receive vitamin A or placebo. Plasma vitamin A level, CD4 lymphocyte count, and HIV load were measured at baseline and 2 and 4 weeks after treatment. Vitamin A supplementation had no significant impact on HIV load or CD4 lymphocyte count at 2 and 4 weeks after treatment. This study suggests that high-dose vitamin A supplementation does not influence HIV load.

Reductions in high-risk drug use behaviors among participants in the Baltimore needle exchange program

OBJECTIVE

To determine whether enrollment in the Baltimore Needle Exchange Program (NEP) was associated with short-term reduction in risky injection practices.

METHODS

Demographic information was collected on NEP participants upon enrollment. A systematic sample of enrollees was interviewed at program entry, 2 weeks, and 6 months later on recent drug-related behaviors. Comparisons were performed using paired t-tests.

RESULTS

Among 221 NEP participants who completed baseline, 2-week and 6-month follow-up visits, significant reductions (p < .01) were reported in using a previously used syringe (21.6%, 11.0%, 7.8%, respectively), lending one's used syringe to a friend (26.7%, 18.4%, 12%, respectively), and several indirect sharing activities. Reductions were reported in the mean number of injections per syringe and the mean number of injections per day (p < .001).

CONCLUSIONS

These results show rapid and mostly large reductions in a variety of risky injection drug use behaviors. Study findings are consistent with earlier reports showing an association between behavioral risk reduction and participation in a needle exchange program.

Incidence and risk factors for hepatitis C among injection drug users in Baltimore, Maryland

Between 1988 and 1996, the incidence of and risk factors for hepatitis C virus (HCV) infection were studied in a cohort of injection drug users in Baltimore, Maryland. By second-generation antibody testing of stored serum samples, 142 participants were found to be susceptible to HCV at the time they entered the study. After a median follow-up of 6.5 years, 43 participants (30.3%) developed antibodies to HCV (anti-HCV). The overall incidence was 6.4 cases per 100 person-years, but a substantial decline in the annual incidence rate was observed after the first 2 years (1988 to 1990, 13.4/100 person-years; 1991 to 1996, 2.3/100 person-years [P = 0.0001 for trend]). Participants who acknowledged active drug use, especially those who acknowledged frequent use and sharing of drug paraphernalia, were at increased risk of HCV infection. However, high-risk sexual practices were not associated with HCV seroconversion. Efforts to reduce HCV infection must be focused on curbing drug use and especially on the sharing of needles and drug paraphernalia.

Syphilis serology in human immunodeficiency virus infection: evidence for false-negative fluorescent treponemal testing

Injection drug users were assessed serologically for human immunodeficiency virus infection and syphilis every 6 months. Treatment histories were reviewed for any high-titer biologic false-positive (BFP) reactors, that is, persons with rapid plasma reagin (RPR) titers > or = 1:4 and negative results for fluorescent treponemal antibody absorption (FTA-ABS) tests. Selected sera were analyzed further by immunoblotting for the presence of antibodies reactive with specific Treponema pallidum antigens. Of 112 BFP reactors, 35 (31%) had at least one RPR test reactive at a dilution >1:8 while the FTA-ABS test remained nonreactive. Five reactors (4.5%) converted from nonreactive to reactive by FTA-ABS test; 4 (3.6%) were reactive by FTA-ABS tests but later became nonreactive. Antibodies to T. pallidum membrane antigens were detected in some samples that were persistently nonreactive by FTA-ABS test. Serologic patterns over time, along with very high-titer BFP reactions and reactivity with T. pallidum-specific antigens, suggest that some BFP reactions may represent FTA-negative syphilis.

Comparison of PCR and hybrid capture methods for detection of human papillomavirus in injection drug-using women at high risk of human immunodeficiency virus infection

We compared Hybrid Capture, a new technique for detection of human papillomaviruses (HPV), with a PCR assay based on L1 consensus primers. By both methods, the HPV prevalence was higher in human immunodeficiency virus (HIV)-positive women than in HIV-negative women. PCR had a higher sensitivity (0.89 versus 0.48) but lower specificity (0.43 versus 0.93) for detection of Pap smear abnormalities, compared to Hybrid Capture. The higher intensity of hybridization signal by PCR was related to higher estimates of viral load by Hybrid Capture.

HIV infection and cognition in intravenous drug users: long-term follow-up

A cohort of 185 HIV-infected injection drug users (IDUs) and seronegative controls was followed with semiannual neuropsychological assessments for up to 4.5 years. Changes in cognitive performance over time were evaluated, and results of seronegative controls were used to adjust for level of education and practice effects. The effects of duration of follow-up, decline in CD4+ count, development of clinical symptoms, antiretroviral use, and diagnosis of AIDS on changes in neuropsychological performance over time were assessed with regression models using the generalized estimating equation approach. Improvement in performance over time, consistent with practice effects, was observed for all measures. The only subtest for which the magnitude of the practice effects was mildly attenuated relative to the seronegative controls was Grooved Pegboard, dominant hand. After adjusting for disease progression and antiretroviral therapy use, none of the time trends for the neuropsychological test scores were significant, suggesting no decline in performance of the seropositive patients relative to the seronegative controls. With development of clinical symptoms, there was a trend in the direction of declining performance. For subjects reporting two or more symptoms but not using antiretroviral therapy, the trend was not significant, whereas having two or more symptoms and using antiretroviral therapy was associated with significantly worse performance on tests of psychomotor speed and memory. With development of AIDS, a significant decline in performance was observed on measures of motor and psychomotor speed as well as memory. There is thus no evidence to suggest that HIV infection in the context of chronic drug and alcohol use significantly alters the frequency or rate of progression of cognitive symptoms. These findings suggest that the natural history of cognitive changes secondary to HIV infection is similar among HIV-infected IDUs and other risk groups such as homosexual/bisexual men.

Phase II evaluation of clinical coding schemes: completeness, taxonomy, mapping, definitions, and clarity. CPRI Work Group on Codes and Structures

OBJECTIVE

To compare three potential sources of controlled clinical terminology (READ codes version 3.1, SNOMED International, and Unified Medical Language System (UMLS) version 1.6) relative to attributes of completeness, clinical taxonomy, administrative mapping, term definitions and clarity (duplicate coding rate).

METHODS

The authors assembled 1929 source concept records from a variety of clinical information taken from four medical centers across the United States. The source data included medical as well as ample nursing terminology. The source records were coded in each scheme by an investigator and checked by the coding scheme owner. The codings were then scored by an independent panel of clinicians for acceptability. Codes were checked for definitions provided with the scheme. Codes for a random sample of source records were analyzed by an investigator for "parent" and "child" codes within the scheme. Parent and child pairs were scored by an independent panel of medical informatics specialists for clinical acceptability. Administrative and billing code mapping from the published scheme were reviewed for all coded records and analyzed by independent reviewers for accuracy. The investigator for each scheme exhaustively searched a sample of coded records for duplications.

RESULTS

SNOMED was judged to be significantly more complete in coding the source material than the other schemes (SNOMED* 70%; READ 57%; UMLS 50%; *p < .00001). SNOMED also had a richer clinical taxonomy judged by the number of acceptable first-degree relatives per coded concept (SNOMED* 4.56, UMLS 3.17; READ 2.14, *p < .005). Only the UMLS provided any definitions; these were found for 49% of records which had a coding assignment. READ and UMLS had better administrative mappings (composite score: READ* 40.6%; UMLS* 36.1%; SNOMED 20.7%, *p < .00001), and SNOMED had substantially more duplications of coding assignments (duplication rate: READ 0%; UMLS 4.2%; SNOMED* 13.9%, *p < .004) associated with a loss of clarity.

CONCLUSION

No major terminology source can lay claim to being the ideal resource for a computer-based patient record. However, based upon this analysis of releases for April 1995, SNOMED International is considerably more complete, has a compositional nature and a richer taxonomy. Is suffers from less clarity, resulting from a lack of syntax and evolutionary changes in its coding scheme. READ has greater clarity and better mapping to administrative schemes (ICD-10 and OPCS-4), is rapidly changing and is less complete. UMLS is a rich lexical resource, with mappings to many source vocabularies. It provides definitions for many of its terms. However, due to the varying granularities and purposes of its source schemes, it has limitations for representation of clinical concepts within a computer-based patient record.

Human immunodeficiency virus infection and infective endocarditis among injecting drug users

Human immunodeficiency virus (HIV) infection and infective endocarditis are serious complications of injection drug use. To determine whether HIV infection may increase the risk of endocarditis beyond that associated with drug injection, we performed a nested case-control study among injecting drug users taking part in an ongoing cohort. We identified 26 participants with infective endocarditis between cohort enrollment (in 1988-1989) and June 1992, through reviews of medical records and death certificates. We matched each endocarditis case with up to five controls (N = 120) on enrollment date, race/ethnicity, and follow-up time. Data were taken from baseline and from the one follow-up visit: the last visit before the endocarditis occurred for cases and the closest visit (+/- 3 months) for controls. We used conditional logistic regression to quantify the association between HIV serostatus at follow-up and subsequent endocarditis, after adjusting for a history of endocarditis or sepsis before enrollment, injection duration, current injection frequency, and a recent history of abscess at injection sites. Among current injectors at follow-up, the adjusted odds ratio (OR) of developing endocarditis for HIV-seropositive subjects with > or = 350 CD4 cells per microliter, compared with HIV-seronegative subjects, was 2.31 [95% confidence interval (CI) = 0.61-8.78]; the corresponding OR for HIV-seropositive subjects with < 350 CD4 cells per microliter was 8.31 (95% CI = 1.23-56.37). These data indicate that HIV-related immunodeficiency may independently increase the risk of infective endocarditis among injecting drug users.

Effect of human immunodeficiency virus on hepatitis C virus infection among injecting drug users

To assess the effect of human immunodeficiency virus (HIV) immunosuppression on ongoing hepatitis C virus (HCV) infection, CD4 lymphocyte counts and serum concentrations of HCV RNA, HIV RNA, and alanine aminotransferase (ALT) were evaluated among members of a cohort of injecting drug users (IDUs). With 100 participants randomly selected at various stages of HIV-related immunosuppression, serum HCV RNA concentrations increased with age (P = .007) and were higher in HIV-positive IDUs with 201-500 (P = .026) and 51-200 (P = .004) CD4 cells/mL than in HIV-negative participants. Among 27 HCV-infected IDUs who acquired HIV infection, serum HCV RNA concentrations varied between semiannual visits by a mean of 0.45 logs, increasing by 0.60 logs after HIV seroconversion (P < .0001), by 0.12 logs each subsequent year (P = .006), and by 0.36 logs per log increase in CD4 cells (P = .01). Serum ALT levels were similar between HIV-positive (40.1 IU/mL) and HIV-negative (45.4 IU/mL) patients (P > .10). While HIV infection and possibly HIV progression are associated with increased HCV RNA levels, other factors appear to affect biochemical and virologic markers of HCV infection in some dually infected persons.

Alcohol use and T-lymphocyte subsets among injection drug users with HIV-1 infection: a prospective analysis

OBJECTIVES

Alcohol use is known to alter immune function and has immunosuppressive effects that may modify T-lymphocyte subpopulations. However, there is no clear evidence regarding the relationship of alcohol use with the progression of immunodeficiency in human immunodeficiency virus-type 1 (HIV-1)-seropositive individuals, particularly injection drug users (IDUs).

METHODS

Using prospective data from a cohort of IDUs in a study of the natural history of HIV infection, we examined the relationship of alcohol use and changes in T-lymphocyte subsets. Among the 2921 IDUs followed semiannually in outpatient clinics, 188 were documented HIV-1 seroconverters with known time of seroconversion. At each visit, all study participants were interviewed, underwent physical examinations, and had blood drawn for laboratory studies. Alcohol use was measured by reported frequency and quantity of alcoholic beverages. Longitudinal analyses included data for up to 5 years postseroconversion. To formally test the association of alcohol use with change in levels of CD4+ and CD8+ cells subsequent to HIV seroconversion, regression models incorporating autocorrelation structure were applied.

RESULTS

Alcohol use was not appreciably related to age, gender, marital status, income, education, or the duration of intravenous drug use. CD4% decreased for all IDUs within the first 5 years after seroconversion, with no significant differences between alcohol categories. CD8% increased for all IDUs, with no significant differences by alcohol category within the first 2 years after seroconversion. However, between 2 to 5 years postseroconversion, there was a statistically significant increase among the heaviest drinkers: CD8% increased 6.9%/year [95% confidence interval (CI): 4.7, 8.0] for the IDUs who reported > 21 drinks/week, 2.4%/year (95% CI: 0.8, 4.0) for IDUs who drank 21 drinks/week or less, and 0.4% (95% CI: -2.1, 2.9) for abstainers. Similar results were obtained for CD4 and CD8 absolute counts.

CONCLUSIONS

In this study population of IDUs, CD8% (but not CD4%) is associated with alcohol consumption early after HIV seroconversion. This is the first prospective study to date to assess the relationship of alcohol use with HIV progression from the time of HIV seroconversion among a cohort of IDUs. If confirmed in future investigations, the findings may have significant implications for prevention and early intervention programs aimed at inhibiting disease progression among HIV-positive IDUs.

Differences in the incidence of hepatitis B and human immunodeficiency virus infections among injecting drug users

Both hepatitis B virus (HBV) and human immunodeficiency virus (HIV) type 1 seroconversions have been considered as outcome measures to evaluate the effectiveness of needle exchange programs. To assess the relationships between incident HBV and HIV infections among injecting drug users (IDUs), seroconversions were prospectively studied among a cohort of 240 HBV- and HIV- seronegative IDUs. The incidence of HBV seroconversion declined from 24.41/100 person-years in 1988 to 0 seroconversions in 1992. In contrast, HIV seroconversion rates varied little from the overall rate of 3.29/100 person-years. HBV seroconversion predicted subsequent HIV seroconversion among male IDUs (relative incidence [RI]= 4.23) but not among female IDUs (RI=0.86). Because of different transmission dynamics, HBV seroconversion probably has limited utility as a surrogate outcome measure for incident HIV. However, HBV seroconversion itself is an appropriate and important outcome measure for evaluation of prevention programs among IDUs.

Effects of anesthesia based on large versus small doses of fentanyl on natural killer cell cytotoxicity in the perioperative period

Surgical stress and general anesthesia suppress immune functions, including natural killer cell cytotoxicity (NKCC). This suppression could be attributable, at least in part, to opiates. We have previously shown that large-dose fentanyl administration suppressed NKCC in rats. The present study sought to compare the effects of two anesthetic protocols, based on large- (LDFA) versus small (SDFA)-dose fentanyl anesthesia on NKCC in the perioperative period. Forty patients were included in this study; half were assigned to each protocol of anesthesia. In each anesthetic group, half the patients were undergoing surgery for malignant diseases, and half for benign conditions. Blood samples were collected during the perioperative period. NKCC was assessed using the chromium release assay. Initially, both types of anesthesia similarly suppressed NKCC, with a peak effect 24 h after surgery. The two types of anesthesia, however, differed in the rate of recovery of NKCC suppression. By the second postoperative day, NKCC returned to control values in the SDFA patients, whereas NKCC was still significantly suppressed after LDFA. These results indicate that LDFA causes prolonged suppression of NK cell function. Whether this suppression might have a long-term impact on the overall outcome, especially in cancer patients, remains to be determined.

Seroepidemiology of hepatitis B virus in a population of injecting drug users. Association with drug injection patterns

To investigate the epidemiology of hepatitis B virus (HBV) infection among injecting drug users, the authors assessed the prevalence of HBV seromarkers among 2,558 injecting drug users recruited through street outreach in Baltimore, Maryland, in 1988-1989. Eighty percent of the drug users had at least one HBV seromarker. HBV seropositivity was associated with increasing age, duration of injecting drug use, African-American ethnicity, injecting drugs at least once daily, and sharing needles or visiting "shooting galleries" during the previous 11 years, but not with high-risk sexual behaviors or a history of sexually transmitted disease. This finding is possibly due to the relative inefficiency of sexual transmission as compared with parenteral transmission in injecting drug users. In addition, HBV seropositivity was strongly associated with seropositivity for hepatitis C virus and human immunodeficiency virus. The authors conclude that HBV transmission among injecting drug users occurs primarily through the sharing of contaminated drug injecting equipment rather than through sexual relations, and that efforts to prevent HBV infection must target injecting drug users early in their injecting careers.

Recent infection with human immunodeficiency virus and possible rapid loss of CD4 T lymphocytes

To assess a hypothesized trend that persons recently infected with the human immunodeficiency virus (HIV) may have more rapid declines in absolute CD4 T-lymphocyte (CD4+ cell) counts than those who were HIV-infected in earlier years, sequential CD4+ cell counts in three groups who had definable dates of HIV seroconversion between 1978 and 1992 were reviewed. The CD4+ cell counts examined were from some of the longest extant studies in the United States: 100 homosexual and bisexual men engaged in ongoing observational cohort studies in San Francisco, Denver, and Chicago since 1978 (Group 1); 89 persons in South Carolina infected after 1986 (Group 2); and 155 injecting drug users participating in an observational cohort study in Baltimore since 1988 (Group 3). For all groups, individually and in the aggregate, mean CD4+ cell counts declined rapidly in the first year after HIV infection and then stabilized. However, there was no clear trend for lower (or higher) CD4+ cell counts by fixed time after HIV seroconversion among those seroconverting in recent compared with earlier calendar years. These data do not support a hypothesized trend for more rapid loss of CD4 T lymphocytes--and, by implication, more pathogenic strains of HIV-1--among persons acquiring HIV infection in recent years.

Correlates of hepatitis C virus infections among injection drug users

Injection drug users are at high risk for hepatitis C virus (HCV) infection. In Baltimore, Maryland, the prevalence of anti-HCV is greater among injection drug users who are black, human immunodeficiency virus (HIV) infected, have injected longer, have injected more frequently, and have injected cocaine than among other injection drug users. HCV infection occurs quickly after the initiation of injecting illicit drugs, with 78% of study participants anti-HCV positive after 2 years of injecting. The prevalence of anti-HCV among injection drug users does not appear to be related to socioeconomic factors or sexual practices. Some injection drug users remain free of anti-HCV even after years of injecting and serologic evidence of other bloodborne pathogens. Some of these injection drug users have HCV infection, demonstrated by HCV RNA in their sera. However, the basis for viral persistence in the absence of anti-HCV and for the absence of HCV infection in long-term drug users is not known. Further studies are indicated to determine the mechanism or mechanisms for the absence of anti-HCV in persons exposed to the virus, because the biologic basis for this condition may elucidate the elements missing in the immune response of the majority of HCV-exposed persons who acquire persistent infection. In addition, interventions to prevent HCV infections should be applied in populations at risk for injection drug use early or before drug use begins.

Temporal trends of incident human immunodeficiency virus infection in a cohort of injecting drug users in Baltimore, Md

OBJECTIVE

To measure the temporal trends in the incidence of infection with human immunodeficiency virus in a cohort of injecting drug users in Baltimore, Md, between 1988 and 1992.

DESIGN

Study subjects were screened for antibodies to human immunodeficiency virus by enzyme-linked immunosorbent assay and confirmed with Western blot. They were followed up at 6-month intervals with repeated serologic screening and comprehensive interviews for human immunodeficiency virus risk factors.

SETTING

Special study clinic.

PARTICIPANTS

A cohort of 2960 participants were recruited and screened between February 1988 and March 1989. Recruitment criteria included an age of 18 years or older, a history of illicit drug injection since 1978, and the absence of the acquired immunodeficiency syndrome; subjects were subsequently tested for human immunodeficiency virus antibodies. Most subjects (85%) were not receiving methadone treatment at baseline and were recruited by word of mouth.

MAIN OUTCOME MEASURE

Human immunodeficiency virus seroconversion.

RESULTS

Of the 2247 seronegative participants at baseline, 1532 were followed up, and 188 (12.3%) had seroconverted by December 1992. The incidence of human immunodeficiency virus infection over time among users declined somewhat, especially among women; the overall incidence was 1.90 per 100 person-semesters, or 3.80% annually. The incidence, adjusted for gender, was higher in younger (< 35 years) than older (> or = 35 years) subjects (relative incidence, 1.75; 95% confidence interval, 1.29 to 2.38) and in women compared with men, adjusted for age (relative incidence, 1.29; 95% confidence interval, 0.95 to 1.80). The relative incidence among active compared with inactive drug users adjusted for age and gender was 1.58 (95% confidence interval, 1.06 to 2.35).

CONCLUSIONS

Although the incidence of human immunodeficiency virus infection in this cohort of injecting drug users in Baltimore declined somewhat during the 4 years of follow-up, especially among women, the persistent annual incidence of nearly 4% during 3 1/2 to 4 1/2 years of observation suggests the need for additional strategies for prevention of infection, especially among those who continue injecting drugs. Newer methods of prevention, such as provision of sterile injection equipment, an effective human immunodeficiency virus vaccine, and wider availability of effective treatment or prevention of drug addiction, are urgently needed in these high-risk populations.

Incidence and risk factors for human T-lymphotropic virus type II seroconversion among injecting drug users in Baltimore, Maryland, U.S.A

To determine the incidence of and risk factors for human T-lymphotropic virus, type II (HTLV-II) seroconversion among injecting drug users (IDUs), specimens from IDUs recruited into the ALIVE Study in 1988/1989 were assayed at baseline for antibody to HTLV with use of enzyme immunoassay and Western blot. Participants were monitored semiannually with venipuncture and interviews. In 1992, the most recent sera of HTLV-negative participants were tested for HTLV with use of enzyme immunoassay and confirmed and typed by Western blot. For positive cases, assays were then performed for all intervening visits to determine the calendar time of seroconversion. Incidence rates were estimated using person-time. Risk factor analysis used a nested case-control design, with up to seven controls per case matched by time of study entry and duration of follow-up. At baseline, 251 HTLV-positive, 22 indeterminate, and 2,574 HTLV-seronegative IDUs were identified. Follow-up of the seronegative IDUs identified 38 seroconverters (all HTLV-II) over 5,813.6 person-years, for a rate of 0.7/100 person-years. Median lag time for seroconversion was 6.8 months. Factors associated with HTLV-II seroconversion included a specific needle-sharing practice called "backloading" within the previous 6 months [odds ratio (OR) = 6.52; 95% confidence interval (CI) = 1.94-21.95] and a baseline history of receiving money for sex (OR = 3.36; 95% CI = 1.32-8.57). Of those with more than one sex partner in the past 6 months, women were more likely than men to seroconvert (OR = 5.77; 95% CI = 1.33-25.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Vitamin A deficiency and wasting as predictors of mortality in human immunodeficiency virus-infected injection drug users

A nested case-control study of vitamin A deficiency and wasting as risk factors for mortality from AIDS and infections was done within a large prospective cohort of human immunodeficiency virus (HIV)-infected injection drug users (IDUs). Fifty adult subjects who died from AIDS and infections were matched with 235 controls who survived. Plasma vitamin A, weight, and body mass index were measured. Mean length of follow-up was 2.4 +/- 1.1 years. Vitamin A deficiency occurred in 50% and wasting occurred in 38% of patients in the last visit before death. CD4 cells count < 200/microL, wasting, and vitamin A deficiency were associated with mortality. There was a higher risk of death in HIV-infected subjects with vitamin A deficiency (odds ratio [OR], 4.6; 95% confidence interval [CI], 1.8-11.3) and wasting (OR, 8.8; 95% CI, 2.7-28.2). Vitamin A deficiency and wasting are common during HIV infection and are independent predictors of mortality in HIV-infected IDUs.

A simple modification in operative technique can reduce the incidence of nonanastomotic biliary strictures after orthotopic liver transplantation

Nonanastomotic strictures after liver transplantations are a source of significant morbidity, often necessitating retransplantation. The purpose of this study was twofold: first to identify features associated with the development of this lesion; second, to make technical modifications that will decrease the incidence of this problem. In the first part of this study, 15 of 131 patients were diagnosed with nonanastomotic biliary stricture. A stepwise logistic-regression analysis associated donor cold ischemic time and dopamine dose with the development of nonanastomotic biliary strictures. All these patients had arterial reconstruction after partial revascularization of the liver with portal venous blood. Because the bile duct receives its blood supply from only the hepatic artery, we hypothesized that the prolonged period of warm ischemia from staged reconstruction of the vascular supply would promote the development of this lesion. In a second part of this study, the stricture rate in 45 patients with simultaneous revascularization using both the hepatic artery and portal vein was compared with that in 83 patients from the first part of this study initially revascularized with portal venous blood. All patients in the second study had grafts preserved using UW solution. Only 1 patient with simultaneous revascularization developed a nonanastomotic biliary stricture. Because we were unable to identify any significant complications related to this method of revascularization, we propose that the hepatic artery and portal vein should be released simultaneously, especially in patients receiving a graft with prolonged storage time.