Complications associated with Staphylococcus aureus bacteremia.

Thirty-nine consecutive Staphylococcus aureus bacteremias were reviewed with particular attention to complications. Thirty-four (87%) of the bacteremias were nosocomial, with intravascular catheters (20 episodes) and dialysis-access sites (six episodes) the most common sources. Complications developed in 36% (14/39) of all bacteremias and in 30% (6/20) of those that were catheter-associated. Acute complications (shock, adult respiratory distress syndrome, disseminated intravascular coagulation) occurred in six patients and were fatal in four. In nine patients metastatic suppurative complications developed, six at sites of preexisting abnormalities. There were no episodes of endocarditis. Most patients received prolonged antibiotic therapy, and the majority of all suppurative complications required surgical intervention. Staphylococcus aureus bacteremia, even when not associated with endocarditis, is a cause of considerable morbidity and mortality in hospitalized patients.

Patterns of use, expenditures, and perceived efficacy of complementary and alternative therapies in HIV-infected patients.

BACKGROUND: Complementary and alternative medicine (CAM) use is common in the general population, accounting for substantial expenditures. Among patients with human immunodeficiency virus (HIV) infection, few data are available on the prevalence, costs, and patterns of alternative therapy use. METHODS: We carried out detailed telephone surveys and medical chart reviews for 289 active patients with HIV in a general medicine practice at a university-based teaching hospital in Boston, Mass. Data were collected on prevalence and patterns of CAM use, out-of-pocket expenditures, associated outcomes, and correlates of CAM use. RESULTS: Of 180 patients who agreed to be interviewed, 122 (67.8%) used herbs, vitamins, or dietary supplements, 81 (45.0%) visited a CAM provider, and 43 (23.9%) reported using marijuana for medicinal purposes in the previous year. Patients who saw CAM providers made a median of 12 visits per year to these providers compared with 7 visits per year to their primary care physician and nurse practitioner. Mean yearly out-of-pocket expenditures for CAM users totaled $938 for all therapies. For the main reason CAM was used, respondents found therapies "extremely" or "quite a bit" helpful in 81 (81.0%) of 100 reports of supplement use, in 76 (65.5%) of 116 reports of CAM provider use, and in 27 (87%) of 31 reports of marijuana use. In multivariable models, college education (odds ratio [OR]=3.7, 95% confidence interval [CI]=1.9-7.1) and fatigue (OR=2.7, 95% CI=1.4-5.2) were associated with CAM provider use; memory loss (OR=2.3, 95% CI=1.1-4.8) and fatigue (OR=0.4, 95% CI=0.2-0.9) were associated with supplement use; and weight loss (OR=2.6, 95% CI=1.2-5.6) was associated with marijuana use. CONCLUSIONS: Patients with HIV infection use CAM, including marijuana, at a high rate; make frequent visits to CAM providers; incur substantial expenditures; and report considerable improvement with these treatments. Clinical trials of frequently used CAMs are needed to inform physicians and patients about therapies that may have measurable benefit or measurable risk.

A model clinic for the initial evaluation and establishment of primary care for persons infected with human immunodeficiency virus.

BACKGROUND: The human immunodeficiency virus (HIV)-infected patients on initial presentation to primary medical care may have extensive problems relating to medical, substance abuse, psychiatric, and social issues. We examined a model for the initiation of primary medical care for patients infected with HIV at a public hospital and presented the clinical, educational, and research benefits associated with such a clinic. METHODS: Eight hundred forty-five consecutive HIV-infected outpatients without primary care, who presented to a municipal hospital HIV intake clinic, the Diagnostic Evaluation Unit, between February 1, 1990 and August 31, 1993, received a multidisciplinary assessment and a facilitated access to medical services. The performance of standardized initial clinical evaluation and adherence to primary care referral were examined. RESULTS: During the most recent study year, more than 90% of patients presenting to the clinic completed the intake process and 95% were seen at the site to which they were referred for primary medical care. Tests for CD4 lymphocytes, syphilis, hepatitis B, and tuberculosis were obtained, pneumococcal vaccinations were administered, and social service assessments were performed in 92% to 98% of patients completing the intake. The clinical setting was a site for involvement in research protocols and provided a focused educational experience concerning outpatient HIV management for medical students and residents. CONCLUSIONS: Establishment of a clinic dedicated to the initial evaluation of HIV-infected persons in a municipal hospital successfully evaluated and linked patients to primary care providers. The clinic structure enabled the standardized performance of appropriate laboratory tests and vaccinations and provided unique educational and research opportunities. We encourage other health care settings to consider the development of similar models for the initiation of medical care for persons infected with HIV.

Lithium carbonate in the treatment of schizophrenia and schizo-affective disorder: review and hypothesis.

The success of lithium carbonate in the treatment of manic-depressive illness has led to its use in many other psychiatric disorders. Within this group, schizophrenia and schizo-affective disorder have come under the closest scrutiny. The literature, however, is difficult to reconcile. Conclusions are often contradictory, methodologies confusing, and well-designed studies few in number. In this paper, the authors have attempted to extract common denominators that may prove of value in delineating those symptoms which predict therapeutic response to lithium carbonate.

Initial assessment of patients infected with human immunodeficiency virus: the yield and cost of laboratory testing.

Our objective was to determine the yield and cost of standardized laboratory testing of HIV-infected patients entering medical care after testing positive for HIV. An HIV staging and referral clinic in a municipal public hospital was our site for a cross-sectional study, and 308 patients were evaluated in the clinic between February 1, 1990 and October 1, 1991. Patients underwent standardized laboratory testing, including hematologic studies, serum chemistries, infectious disease serologies, and chest radiographs. The percentage of abnormal results for each test was determined. Abnormal results were stratified as mild or severe. They were also examined with regard to whether injection drug users or other patient subgroups had higher percentages of abnormalities. Changes and Medicare reimbursements for the tests were also determined. There were substantial numbers of abnormalities in all types of laboratory testing. Only 3% of patients had normal CD4 lymphocyte counts; 85% had counts of < 500/mm3, and 35% were < 200/mm3. Forty-four percent of patients had at least one abnormal hematologic study; 8% were severe. Nearly 75% had abnormal liver function tests; 20% of these were severe abnormalities. Fifteen percent of patients were PPD-positive, and > 50% were anergic. Fourteen percent had a positive nonspecific test for syphilis, and 7% had a positive confirmatory test. Fourteen percent of patients had an abnormal chest radiograph.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors associated with initiation of primary medical care for HIV-infected persons.

PURPOSE: To examine the degree of immune dysfunction of human immunodeficiency virus (HIV)-infected patients at the time of presentation and to identify factors associated with early and late initial primary medical care for HIV infection as measured by CD4+ lymphocyte count. PATIENTS AND METHODS: Two hundred fifty-one consecutive outpatients without prior primary care for HIV infection were assessed at a municipal hospital HIV intake clinic (derivation group). Sociodemographic and clinical variables were examined for their association with CD4+ cell count on presentation in bivariate and stepwise linear regression analyses. Variables of interest were examined in 123 similar patients at a second site to assess the generalizability of our findings (validation group). RESULTS: In the derivation group, 30% of patients presented for initial primary care with CD4+ cell counts less than 200/mm3, 51% had counts from 201/mm3 to 500/mm3, and only 19% had counts greater than 500/mm3. Twenty-seven percent of patients had delayed seeking medical care for longer than 1 year and 12%, for more than 2 years after an initial positive HIV serologic evaluation. Three variables were significant and independent predictors of CD4+ cell count on presentation: Haitian ethnicity (P = 0.05) and HIV-related symptoms (P = 0.005) were associated with lower CD4+ cell counts; and female sex (P = 0.009) was associated with higher CD4+ cell counts. With HIV-related symptoms excluded from the model, a history of cocaine use was also a significant predictor for higher CD4+ cell count (P = 0.02). In the validation group, which included few Haitians, results for female sex and HIV-related symptoms showed a similar association. CONCLUSIONS: Most HIV-infected patients presented for primary care with advanced immune dysfunction. A substantial percentage of patients waited over a year to initiate medical care after testing positive for HIV. Haitian patients presented later for primary HIV care as measured by CD4+ cell count. Women presented with significantly higher CD4+ cell counts than did men. Since few characteristics examined could clearly identify the majority of late-presenting HIV-infected patients, improved general and targeted efforts are needed to link all HIV-infected people with primary medical care before the development of advanced disease.

Compliance with zidovudine therapy in patients infected with human immunodeficiency virus, type 1: a cross-sectional study in a municipal hospital clinic.

PURPOSE: To determine the extent of and clinical variables associated with zidovudine compliance. PATIENTS AND METHODS: A survey of 83 patients infected with human immunodeficiency virus (HIV) followed in a municipal hospital clinic was performed. Compliance histories were validated by serum and urine zidovudine levels. Patient characteristics included 46% white, 63% with a history of intravenous drug use, and 59% reporting a diagnosis of acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC). The main outcome measure was greater than 80% compliance with prescribed doses of zidovudine over the previous week. RESULTS: Sixty-seven percent of the study patients reported greater than 80% compliance with prescribed doses of zidovudine over the previous week. The most common explanations given for missing a dose were "forgot to take zidovudine" and "did not have the medication with me." Five variables were independently associated with greater than 80% compliance as determined by stepwise multiple logistic regression: patient belief that zidovudine prolongs life (odds ratio [OR] 9.3, [95% confidence interval (CI) 2.4, 36.7]), a diagnosis of AIDS or ARC (OR 5.5, [CI 1.5, 20.4]), use of a medication timer (OR 4.4, [CI 1.0, 19.1]), no history of intravenous drug use (OR 3.7, [CI 1.0, 14.2]), and taking one to three other medications with zidovudine. CONCLUSIONS: High compliance with zidovudine was achieved by HIV-infected patients in a municipal hospital clinic, many of whom had a history of intravenous drug use. Compliance with zidovudine may be enhanced by a patient's belief that it prolongs life and the use of a medication timer for proper dosing.

Improving medical residents' attitudes toward HIV-infected persons through training in an HIV staging and triage clinic.

PURPOSE: To assess the effect of a weekly outpatient clinic for staging and triage of newly identified human-immunodeficiency-virus (HIV)-infected patients on medical residents' attitudes and knowledge regarding care of HIV-infected persons. METHOD: Twenty-one second- and third-year medical residents who participated in the Diagnostic Evaluation Unit (DEU) of Boston City Hospital's Clinical AIDS Program from July 1991 through December 1991 were matched with a control group of 20 residents. Both groups of residents were asked to anonymously complete self-administered questionnaires before, immediately after, and three months following the DEU rotation. Responses were compared using repeated measures analysis of variance, two-tailed t-tests, and chi-square analysis. RESULTS: Compared with the controls, the DEU residents showed an increased sense of feeling adequately trained to provide primary care to HIV-infected patients immediately after the rotation (p = .0002), which was sustained at the three-month follow-up (p < .001). Compared with the controls, the DEU residents also showed improved general attitudes toward treating persons with acquired immune deficiency syndrome, which persisted at the three-month follow-up, although these changes were not significant. CONCLUSION: The experience in an HIV staging and triage clinic had a positive effect on the confidence and attitudes of the medical residents. Similar training experiences may increase the willingness and capacity of physicians to provide primary care to HIV-infected persons.

Brief communication: detecting depression: providing high quality primary care for HIV-infected patients.

Depression is common among HIV-infected patients, but little is known about risk factors for depression in this population. Several studies before protease inhibitors became available have reported inconsistent associations between depression and disease severity. Delivering high quality HIV care includes adequate detection and treatment of depression. The objective of this study was to describe the prevalence and correlates of depression among a contemporary group of HIV-infected patients. The setting and design for the study was a chart abstraction for HIV-infected patients in a primary care practice in Boston, Mass, in June 1997. Among 275 HIV-infected patients, depression was documented in 147 patient charts (53%), half of whom (n = 73, 27%) also received antidepressant medications. We used multivariable logistic regression to identify risk factors for depression among patients with both a chart diagnosis of depression and current antidepressant medication use. We observed increased risk of depression among patients with a history of substance use (odds ratio 2.7, 95% confidence interval 1.5-4.7), recent medical hospitalization (2.6, 1.4-5.0), and homosexual risk behavior (2.1, 1.1-4.2). Depression remains a common problem for HIV-infected patients, particularly among those with history of substance abuse, medical hospitalization, or homosexual risk behavior. Routine screening for depression in this population with special attention to those at higher risk may offer opportunities for earlier diagnosis and treatment.

Pathogenesis, natural history, and classification of HIV infection.

Much has been learned about the pathogenesis and natural history of AIDS over the past decade. The causative agent is now known to be a human retrovirus that selectively infects CD4 lymphocytes and monocyte/macrophages. The structure, genetic composition, and major proteins of HIV have been identified, and its basic pathophysiology defined. Antibody tests have been developed to screen for HIV infection, and antiretroviral agents devised for its treatment. The viral and host factors that protect against HIV infection and modulate its course, once established, remain to be clarified. HIV infection produces a chronic disease characterized by a primary syndrome, clinical latency period, and manifestations of increasing immunosuppression. It encompasses a wide clinical spectrum ranging from the absence of symptoms to the presence of life-threatening opportunistic diseases. Clinical and laboratory predictors of disease progression have been identified. Neither of the published classification systems for HIV has gained widespread acceptance by the medical community. Staging of patients based on the management implications of their CD4 lymphocyte count is perhaps of greatest practical value to the clinician.

Factors associated with discontinuation of antiretroviral therapy in HIV-infected patients with alcohol problems.

Although mortality rates among HIV-infected populations have declined with the advent of combination antiretroviral therapy (ART), patients with substance use disorders have benefited less from these therapies. While adherence to ART has been well studied, less is known about factors associated with discontinuation of ART. The aim of this study is to investigate predictors of discontinuation of ART in HIV-infected patients with alcohol problems, focusing on their substance use and depressive symptoms. The study cohort (n=266) was prospectively assessed with biannual standardised interviews between 2001 and 2005. Four predictor variables (cocaine, heroin, heavy alcohol use and substantial depressive symptoms) were assessed six months prior to the outcome (ART discontinuation). Longitudinal logistic regression models examined the association between predictor variables and ART discontinuation adjusting for age, gender, race/ethnicity, homelessness, CD4, HIV RNA and HIV Symptom Index. Subjects were 77% male; 43% black; 22% homeless; 45% used cocaine; 20% used heroin; 29% had heavy alcohol use; and 40% had substantial depressive symptoms. Discontinuation occurred in 135 (17%) of the observations (n=743). In bivariate analyses, cocaine use, heroin use and depressive symptoms were significantly associated with ART discontinuation but heavy alcohol use was not. In the multivariable model, substantial depressive symptoms (adjusted odds ratio (AOR)=1.66; 95% confidence interval (CI): 1.04, 2.65) but not cocaine (AOR=1.28; 95%CI: 0.76, 2.16) or heroin use (AOR=1.27 95%CI: 0.66, 2.44), remained significantly associated with ART discontinuation. Among HIV-infected adults with alcohol problems, depressive symptoms, but not substance use, predicted subsequent ART discontinuation. Recognition and treatment of depressive symptoms in this population may result in better maintenance of ART and its associated clinical benefits.

Meeting information needs: analysis of clinicians' use of an HIV database through an electronic medical record.

We developed an on-line medical record (OMR) and integrated it into a mature hospital information system. The OMR provides a number of information resources for the care of patients infected with the human immuno-deficiency virus (HIV), including drug information, an on-line version of a newsletter on AIDS, an on-line version of a textbook on HIV, and an index of research protocols that actively enrolls patients. As part of an 18-month clinical trial of this system, we monitored the use of the information resources and whether or not the resources were being used at the time of a patient's visit. During 16% of office visits of HIV-infected patients, clinicians viewed some HIV-related information. Forty-four of 70 clinicians looked at drug information (the most popular resource) 347 times (eight times per person). Two thirds of each clinician's use of the information was through a patient's electronic record, and about half of those (or one third of each clinician's use) were at the time of a patient's visit. Use of other information resources was somewhat less, but the proportion of uses during a patient's visit was similar. Because of this high level of use, we conclude that clinicians need information resources at the point of patient care and that the electronic medical record is an ideal medium through which to convey this information to providers.

Delays in protease inhibitor use in clinical practice.

OBJECTIVE: To determine the clinical factors associated with delayed protease inhibitor initiation. DESIGN: Chart review and telephone survey. SETTING: General medicine practice at an academic medical center in Boston, Mass. PATIENTS: One hundred ninety patients living with HIV and a viral load of more than 10,000 copies/ml. MEASUREMENTS AND MAIN RESULTS: The main outcome measurement was time to first protease inhibitor prescription after first elevated HIV viral load (>10,000 copies/ml). In this cohort, 190 patients had an elevated viral load (median age 39; 87% male; 12% history of injection drug use; 63% AIDS; 53% with depression; 17% history of pneumocystis pneumonia; 54% CD4 <200). In Cox proportional hazards modeling, significant univariate correlates for delayed protease inhibitor initiation were higher CD4 cell count (hazard ratio [HR] 2. 38 for CD4 200-500 compared with <200, 95% confidence interval [CI] 1.59, 3.57; and HR 8.33 for CD4> 500; 95% CI 2.63, 25.0), higher viral load (HR 0.43 for each 10-fold increase; 95% CI 0.31, 0.59), injection drug use (HR 2.08; 95% CI 1.05, 4.17), AIDS (HR 0.24; 95% CI 0.15, 0.36), and history of pneumocystis pneumonia (HR 0.32; 95% CI 0.21, 0.49). In multivariate models adjusted for secular trends in protease inhibitor use, factors significantly associated with delay of protease inhibitor initiation (p <.05) were higher CD4 cell count (for CD4 200-500, HR 2.63; 95% CI 1.61, 4.17; for CD4> 500, HR 11.11; 95% CI 3.57, 33.33), higher viral load (HR 0.66 for each 10-fold increase; 95% CI 0.45, 0.98), history of pneumocystis pneumonia (HR 0.57; 95% CI 0.37, 0.90), history of depression (HR 1. 49; 95% CI 1.03, 2.13), and history of injection drug use (HR 2.70; 95% CI 1.35, 5.56). CONCLUSIONS: HIV-infected patients with higher CD4 cell counts or a history of depression or history of injection drug use have significant and lengthy delays of protease inhibitor therapy. Although some delays may be clinically appropriate, enhancement of provider and patient education might prove beneficial. Further research should examine reasons for delays in protease inhibitor initiation and their appropriateness.

Controversies in the management of HIV-related illnesses.

The care of patients who have HIV infection requires technical competence, skill in clinical decision making, a commitment to continuing self-education, the ability to collaborate with medical and community-based service providers, and attention to the psychological and ethical aspects of patient care. General internists bring these attributes to their work and will be increasingly involved in meeting the challenges presented by the AIDS epidemic. Controversial issues in the management of HIV illness include: assessment and management of latent syphilis in patients with intercurrent HIV infection; risk assessment and postexposure zidovudine prophylaxis of health care workers after occupational accidents; determination of the risk of reactivation tuberculosis in HIV-infected individuals; and treatment or nontreatment of infections with the Mycobacterium avium complex in symptomatic patients. Patients illustrating these management problems are presented by progressive disclosure; the points made in discussion by a panel of general internists and AIDS specialists are presented.