Comparison of colorectal cancer screening and diagnoses in HIV-positive and HIV-negative veterans.

Non-AIDS defining malignancies, including colorectal cancer (CRC), are emerging as significant problems in HIV-infected people. Some data suggest that HIV-positive patients have higher incidence of CRC at younger ages than those who are HIV-negative. This investigation examined CRC rates and screening types and trends between 943 HIV-infected cases and their age, race, and gender matched HIV-negative controls (n = 943) from 1 January 2005 to 31 December 2008 at the Atlanta VA Medical Center. The most common screening type among these patients was fecal occult blood testing (FOBT), but colonoscopies were more common in the controls (16.4% for cases, 27.5% for controls; p < 0.0001). Almost half of all patients included in this analysis did not have any screening for CRC during the four years of follow-up even though average age was 55 years. Fifty-one percent of cases had at least one screening test during follow-up compared to 48% of the controls; 7.6% of the cases had a screening each of the four years compared to only 2.4% of the controls (p < 0.0001). Ten HIV-positive patients were diagnosed with CRC during the study period compared to no CRC diagnoses among controls (p = 0.0015), though there was no difference in the diagnosis of colon polyps (4.6% vs. 5.1%, p = 0.5911). These data also suggest a discrepancy in CRC incidence between race and age groups: 80% of HIV-positive cases diagnosed with CRC during the study were black and two were less than 50 years of age. Future studies will need to address whether different recommendations are needed for screening based on HIV status, younger age, or race.

Evaluation of the impact of direct plating, broth enrichment, and specimen source on recovery and diversity of methicillin-resistant Staphylococcus aureus isolates among HIV-infected outpatients.

We compared recovery of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) from nasal and groin swab specimens of 600 HIV-infected outpatients by selective and nonselective direct plating and broth enrichment. Swabs were collected at baseline, 6-month, and 12-month visits and cultured by direct plating to mannitol salt agar (MSA) and CHROMagar MRSA (CM) and overnight broth enrichment with subculture to MSA (broth). MRSA isolates were characterized by pulsed-field gel electrophoresis (PFGE), staphylococcal cassette chromosome mec (SCCmec) typing, and PCR for the Panton-Valentine leukocidin. At each visit, 13 to 15% of patients were colonized with MRSA and 30 to 33% were colonized with methicillin-susceptible S. aureus (MSSA). Broth, CM, and MSA detected 95%, 82%, and 76% of MRSA-positive specimens, respectively. MRSA recovery was significantly higher from broth than CM (P ≤ 0.001) or MSA (P ≤ 0.001); there was no significant difference in recovery between MSA and CM. MSSA recovery also increased significantly when using broth than when using MSA (P ≤ 0.001). Among specimens collected from the groin, broth, CM, and MSA detected 88%, 54%, and 49% of the MRSA-positive isolates, respectively. Broth enrichment had a greater impact on recovery of MRSA from the groin than from the nose compared to both CM (P ≤ 0.001) and MSA (P ≤ 0.001). Overall, 19% of MRSA-colonized patients would have been missed with nasal swab specimen culture only. USA500/Iberian and USA300 were the most common MRSA strains recovered, and USA300 was more likely than other strain types to be recovered from the groin than from the nose (P = 0.05).

Methicillin-resistant Staphylococcus aureus colonization in HIV-infected outpatients is common and detection is enhanced by groin culture.

SUMMARYAlthough high rates of clinical infection with methicillin-resistant Staphylococcus aureus (MRSA) have been reported in HIV-infected adults, data on MRSA colonization are limited. We enrolled HIV-infected adults receiving care at the Atlanta VA Medical Center. Swabs from each participant's nares and groin were cultured with broth enrichment for S. aureus. Of 600 HIV-infected adults, 79 (13%) were colonized with MRSA and 180 (30%) with methicillin-susceptible S. aureus. MRSA pulsed-field gel electrophoresis types USA300 (n=44, 54%) and USA500/Iberian (n=29, 35%) predominated. Inclusion of groin swabs increased MRSA detection by 24% and USA300 detection by 38%. In multivariate analysis, MRSA colonization compared to no MRSA colonization was associated with a history of MRSA clinical infection, rarely or never using condoms, and contact with prisons and jails. In summary, the prevalence of MRSA colonization was high in this study of HIV-infected adults and detection of USA300 was enhanced by groin culture.

Major airway injury in closed chest trauma.

Major fracture of the intrathoracic airway following closed chest trauma is a potentially lethal injury which can be repaired successfully if the diagnosis is made early, Cough, dyspnea cyanosis, hemoptysis, mediastinal emphysema, or pneumothorax not responding to drainage via intercostal tube and a deterioration of the patient's clinical condition out of proportion to the apparent closed chest injury, should alert the clinician to the possiblity of this entity. This report describes the findings in a patient with a longitudinal disruption of the entire intrathoracic trachea and the findings in a second patient with complete transection of the right main bronchus. Each was repaired primarily, with eventual recovery, The principles of management of this difficult group of injuries are reviewed.

Validation of the AMPFlSTR SGM plus system for use in forensic casework.

The AMPFlSTR((R)) SGM Plus system is a commercially available STR multiplex produced by Applied Biosystems, a division of Perkin Elmer, Foster City, California, USA that supersedes SGM. The multiplex contains the six SGM loci, amelogenin and four additional loci. These additional loci are D3S1358, D19S433, D16S539 and D2S1338. Consequently, the match probability is significantly improved (conservatively quoted as 1 in 10(9) for reporting a full profile match). The system was subjected to validation. For example, ageing and degradation studies demonstrated semen stains to be the most stable evidence type, whereas buccal scrapes were the least stable. An apparent rise in the sensitivity increases the chance of obtaining successful results from the more difficult samples submitted for analysis. Two of the new loci (D3S1358 and D19S433) are low molecular weight (between 100 and 150 base pairs); this improved the success rates of the degraded samples where high molecular weight loci may drop out. Of 26 non-primates tested, four gave results that appeared as single peaks and were unlikely to cause interpretation problems. None of the 19 micro-organisms tested gave discernible results. Extensive casework and simulated casework studies demonstrated that SGM and SGM plus results were comparable. There was one example of a null allele (primer binding site mutation) recorded at the HUMFIBRA locus (in both systems). However, a concordance study of 1000 samples using both SGM and SGM plus did not demonstrate any differences in typing.

Hepatitis B virus and HIV coinfection: relationship of different serological patterns to survival and liver disease.

OBJECTIVES: Eighty per cent of HIV-positive patients show evidence of past or current infection with hepatitis B virus (HBV). The impact of chronic HBV infection or the presence of isolated HBV core antibody on survival in the era of highly active antiretroviral therapy (HAART) has not been well studied. METHODS: This retrospective analysis included patients from the HIV Atlanta Veterans Affairs Cohort Study (HAVACS). This cohort comprises 2818 HIV-positive patients followed since 1982. For this analysis, 1685 patients with available HBV serologies were included, based on laboratory records available since 1992. Adjusted survival analyses were performed for patients showing any of four serological patterns for HBV: (1) surface antigen positive (chronic HBV infection), (2) isolated core antibody, (3) surface antibody with or without core antibody (resolved/vaccinated) and (4) no HBV markers (negative group). Risk factors for liver disease were identified. RESULTS: A trend was seen for a lower survival rate from AIDS to death in the chronic HBV infection group compared with the negative group [hazard ratio (HR) 1.43; P=0.118]. The only independent predictor of lower survival rate was hepatitis C virus positivity (HR 1.62; P=0.008). Protective factors were use of HAART (HR 0.40; P=0.0003), use of lamivudine (HR 0.36; P<0.0001) and use of tenofovir (HR 0.23; P<0.0001). Survival from HIV diagnosis to death was not different among the HBV groups. Isolated core antibody patients did not have a lower survival rate compared with those with resolved HBV infection. Patients with chronic HBV infection were 3.5 times more likely to have liver disease than those with no HBV infection (P<0.02). CONCLUSIONS: There is a trend towards a lower survival rate in patients with HIV and chronic HBV infection, but the difference did not reach statistical significance. The presence of isolated core antibody was not associated with a lower survival rate.

Antiretroviral therapy in HIV-positive men is associated with increased apolipoprotein CIII in triglyceride-rich lipoproteins.

OBJECTIVES: Dyslipidaemia has become a common problem in HIV disease, especially in patients on current antiretroviral therapy. However, the pathogenic mechanisms involved are not well understood or documented using conventional lipid measurements. METHODS: Using a cross-sectional design, the prevalence of abnormal standard lipid measurements and novel biomarkers for abnormal lipid metabolism was determined in 271 HIV-positive men from two HIV clinics in Atlanta, GA, USA. RESULTS: A total of 147 men were treated with protease inhibitors (PIs) for >3 months (54%), 84 were treated with nonnucleoside reverse transcriptase inhibitors (NNRTIs) for >3 months (31%) and 40 had not received antiretroviral therapy in the past 3 months (15%). Patients being treated with a PI had higher total cholesterol and triglyceride (TG) levels than patients on no therapy (P<0.05 for each). Patients in the NNRTI group had higher TG, lower high-density lipoprotein (HDL) levels, and higher low-density lipoprotein (LDL) levels than patients on no therapy (P<0.05 for each). Patients treated with either PIs or NNRTIs were more likely to have higher apolipoprotein CIII (apoCIII) levels (P<0.05 for each) than patients on no therapy. Elevated TG was associated with disproportionably elevated apoCIII levels in both treatment groups. CONCLUSIONS: In this cross-sectional study of HIV-infected men, either PI or NNRTI therapy elevated levels of TG and apoCIII. Higher concentrations of apoCIII in apoB-containing lipoproteins [very low-density lipoproteins (VLDLs), intermediate density lipoprotein (IDL) and LDLs] have been predictive of an increased incidence of coronary events in clinical trials and more rapid progression of coronary lesions measured by angiography. These findings, on a background of an older population with additional risk factors of smoking and diabetes, portend future atherosclerotic events in these patients.

The effectiveness of three different strengths of chlorhexidine mouthrinse.

Dental caries in dentate elderly patients may be controlled with chlorhexidine. The purpose of this study is to establish the effectiveness of two low-concentration chlorhexidine mouthrinses in reducing the microbial counts of cariogenic bacteria in a sample of institutionalized elders. Stimulated saliva samples from all subjects before treatment produced counts greater than or equal to 105 colony-forming units (CFU)/mL of lactobacilli and/or mutans streptococci. Treatment consisted of daily rinsing with 4.0 mL of mouthrinse before bed for 14 days. Bacterial counts were re-assessed two weeks after commencing treatment. The mean reduction in mutans streptococci counts in subjects receiving the regular-strength chlorhexidine mouthrinse (Group B) was significantly greater than for subjects using either of the low-concentration rinses (Groups A and C). These findings failed to demonstrate the effectiveness of the lower-concentration mouthrinses (Groups A & C).

Dumbbell granulomatous abscess of the chest wall following needle biopsy of the pleura.

A 38-year-old woman who had a Cope needle biopsy of the pleura was treated for plural tuberculosis on the basis of a positive PPD-S skin test and presence of caseating granulomas in the pleural biopsy. Ten months later she developed a tender, subcutaneous nodule in the area of the previous needle biopsy. Surgical exploration revealed a dumbbell abscess through the chest wall communicating with an area of consolidation in the right middle lobe. En bloc surgical resection of the abscess and peripheral portion of the right middle lobe was curative, although all pathologic and cultural studies of the resected tissue were non-diagnostic.

Bronchopancreatic fistula following traumatic rupture of the diaphragm.

A bronchopancreatic fistula developed in a 14-year-old boy two weeks following transabdominal splenectomy and repair of a ruptured diaphragm. This unusual entity should be suspected when a patient with pancreatitis or pancreatic trauma has pleural complications associated with profuse, frothy sputum. The diagnosis is established by the presence of high levels of amylase in the sputum or by the appearance in the sputum or the bronchi of dye or contrast material injected into the external fistula. The primary goal of treatment, in addition to the management of the thoracic complications, is subdiaphragmatic control of the pancreatic fistula. A brief summary of seven previously reported cases is presented.

Patterns of inpatient surgeries for the top four cancers in the United States, National Hospital Discharge Survey, 1988-95.

BACKGROUND: At a time when the population is aging and medical practices are rapidly changing, ongoing surveillance of surgical treatments for cancer is valuable for health services planning. METHODS: We used data from the National Hospital Discharge Survey for patients with discharge diagnoses of lung, prostate, female breast, and colorectal cancer during 1988-95 to estimate population-based rates and numbers of inpatient surgical procedures. RESULTS: In 1988-91, rates of lobectomy for lung cancer were significantly higher in males than females. By 1994-95, the male/female differences had largely disappeared due to increasing trends among females and decreasing trends among males. During 1988-95, surgeries on the large intestine for colorectal cancer, including right hemicolectomy and sigmoidectomy, decreased significantly, as did abdominoperineal resections of the rectum. Anterior resections of the rectum increased significantly. Radical prostatectomies for prostate cancer increased from 34,000 in 1988-89 to 104,000 in 1992-93 and then decreased to 87,000 in 1994-95; rates followed a similar pattern. Finally, the number and rates of inpatient mastectomies for female breast cancer decreased over the study period (from 219,000 to 180,000 and from 78.8 to 61.5 per 100,000, respectively). CONCLUSION: These trends in inpatient surgeries for the major cancers in the US probably reflect changes in disease occurrence and modified treatment recommendations.