Marked declines in human immunodeficiency virus-related mortality in Chicago in women, African Americans, Hispanics, young adults, and injection drug users, from 1995 through 1997.

BACKGROUND: Declines in human immunodeficiency virus (HIV)-related mortality between 1995 and 1996 were seen across the United States but were small to nonexistent among people in marginalized sectors who are most likely to contract HIV and die of its effects. No comprehensive analysis describing HIV-related mortality in 1997 was available. OBJECTIVE: To describe Chicago's HIV-related mortality trends up to and including 1997, with specific attention focused on marginalized populations. METHODS: An analysis of cross-sectional HIV-related mortality data with emphasis on the years 1995 through 1997 was conducted for Chicago, Ill. Numbers, proportions, and rates of declines in HIV-related deaths were examined for the city as a whole and also among those diagnosed at Cook County Hospital, as a proxy for people with very low socioeconomic status. RESULTS: Between 1995 and 1996 there was an overall decline of 19% in HIV-related mortality in Chicago but small or no declines among women, African Americans, Hispanics, injection drug users, and people aged 20 to 29 years and more than 50 years. Between 1995 and 1997 there was an overall decline of 61%. At that time the declines were spread more evenly across diverse groups. There were almost no significant differences between the declines for these groups at Cook County Hospital and in the rest of Chicago. CONCLUSIONS: The HIV-related mortality has fallen dramatically in Chicago since 1995, the year of its maximum. During 1997, declines were seen among all groups. Declines were also seen among the most disenfranchised of the city. Access to care and the new combination therapies are apparently sustaining life for many in Chicago.

Altered T-lymphocyte subsets in hospitalized intravenous drug abusers.

Baseline immunologic abnormalities were identified in 16 hospitalized intravenous drug abusers ( IDAs ) without acquired immune deficiency syndrome (AIDS). Twelve (75%) of 16 had inverted helper-suppressor ratios. In seven patients (44%), the abnormal ratio resulted from an increase in the absolute number of suppressor cells with a normal number of helper T lymphocytes. In five patients (31%), the reduced ratio resulted primarily from decreased helper cells, immunophenotypic findings similar to those seen in patients with AIDS. These findings are similar to what has been noted in other groups at risk for AIDS. Longitudinal follow-up as well as studies of "healthy" IDAs are required to understand the prognostic implications of these data.

Current antiretroviral therapy and its impact on human immunodeficiency virus-related wasting.

Recent improvements in the management of people living with human immunodeficiency virus (HIV) disease in the United States have led to remarkable reductions in HIV-related morbidity and mortality. The Centers for Disease Control and Prevention recently reported substantial reductions in acquired immunodeficiency syndrome (AIDS)-related opportunistic infections and conditions, including HIV-related wasting. These achievements followed the introduction of the new class of antiretroviral therapies, the aspartyl protease inhibitors, and their use in combination with nucleoside inhibitors in so-called highly active antiretroviral therapies. In an effort to provide guidance for clinicians in HIV care, the Office of AIDS Research, United States Department of Health and Human Services recently convened a panel of experts to set clinical practice guidelines for the use of antiretroviral therapy in adults and adolescents. This article summarizes the new standard of care for the use of HIV therapies. It also reviews recent data suggesting that combination therapy has altered the natural history of HIV infection and has reduced the incidence of HIV-related nutritional disturbances and wasting.

Comparison of 21 vs. 25 mm gastrojejunostomy in the gastric bypass procedure--early results.

BACKGROUND: Many bariatric surgeons consider a small gastrojejunostomy stoma critical to the success of gastric bypass. METHODS: We retrospectively compared a 21 vs. 25 mm gastrojejunostomy in 50 patients undergoing gastric bypass for morbid obesity. RESULTS: 31 patients were constructed with a 21 mm EEA, group I, and 19 with a 25 mm, group II. Average percent of excess body weight lost was 61%, 65%, and 64% at 12, 15, and 18 months follow-up in the group I patients, vs. 61%, 67%, and 69% in the group B patients. Differences were not significant. Complaints of nausea, vomiting, and/or dysphagia were similar between the groups. CONCLUSION: The choice of a 21 or 25 mm gastrojejunostomy does not appear to alter the success of gastric bypass surgery and can be based upon surgeon preference.

Isospora belli and Cryptosporidium sp. from a patient not suspected of having acquired immunodeficiency syndrome.

Several protozoa including Cryptosporidium sp. and Isospora belli were found in a stool specimen from a patient not suspected of having Acquired Immunodeficiency Syndrome (AIDS). As a result of the parasitologic findings, serologic tests were ordered that verified the diagnosis of AIDS. All stool specimens are routinely tested for presence of acid fast organisms with a modified acid fast technique.

PCB and dioxin re-entry criteria for building surfaces and air.

A number of fires involving polychlorinated biphenyl (PCB)-containing transformers and capacitors have occurred in the United States. PCB fires generate by-products such as polychlorinated dibenzofurans (PCDFs) and polychlorinated dibenzodioxins (PCDDs) and, when the transformer is in a building, contaminate the interior. Considerable concern exists over the potential human health effects associated with exposure by inhabitants to residual levels of PCBs, PCDFs and PCDDs. Office workers, for example, may be exposed to these chlorinated compounds via inhalation of contaminated particulates and vapors, dermal contact with contaminated surfaces, and incidental ingestion of dusts. A wide range of re-entry or cleanup levels have been developed for PCDDs and PCBs to protect workers who re-occupy a building following a PCB fire. Re-entry criteria have been used by property owners and regulatory agencies to determine whether the building is safe to re-occupy or to determine the extent of needed remediation. This paper presents a mass balance approach to deriving risk-based re-entry surface and air criteria for PCBs and PCDD/PCDFs. These criteria were based on a lifetime risk level of 10(-5), recent toxicological data on PCDDs and PCBs, and plausible exposure scenarios. Our analysis suggests that 125 ng/m2 2,3,7,8-TCDD TEQ for surfaces and 10 pg/m3 for air are acceptable. Based on Aroclor 1260, risk-based re-entry criteria for PCBs on surfaces and in air were 750 micrograms/m2 and 0.1 microgram/m3, respectively. In comparison to most previous guidelines, these risk-based criteria are less stringent, but can still be considered conservative. The surface criteria are 5 to up to 125 fold higher than previous guidelines. Air criteria range up to 5 times higher than criteria used at past PCB fire sites. Air concentrations associated with these were modeled and were negligible. For PCBs in air, the NIOSH guideline of 1 microgram/m3 is also appropriate for occupational settings.

Seizure after exercise in the heat: recognizing life-threatening hyponatremia.

A 20-year-old military recruit suffered a generalized tonic-clonic seizure following 9 hours of moderate activity in a hot, humid environment. He had drunk at least 5.8 L of plain water before the seizure, and laboratory studies revealed that his serum sodium concentration was 113 mmol/L. Overconsumption of fluids during exercise may precipitate acute hyponatremia, a potentially life-threatening medical condition. Prompt correction of serum sodium in acute exertional hyponatremia is important to reduce the risk of permanent neurologic sequelae or death. Recommendations for prevention include ingesting the correct amount of fluid for the activity (the most important method) and consuming adequate salt through diet or beverage.

Physician use of the HIV antibody test. The need for consent, counseling, confidentiality, and caution.

KIE: The author, a physician at the AIDS Service of Chicago's Cook County Hospital, examines some of the potential harms to patients of indiscriminate HIV antibody testing. He maintains that physicians have a responsibility to educate themselves about the meaning, appropriate use, and adverse consequences of the test and to encourage voluntary HIV antibody testing for persons at risk. Tests should be preceded by informed consent after full disclosure of risks and benefits, accompanied by counseling regarding HIV and AIDS transmission and prevention, and followed by post-test counseling. Strict confidentiality should be maintained at every step in the procedure. Sherer cautions physicians about confirming positive results and the occurrence of false negative tests and urges counseling concerning behavioral change for all at-risk persons irrespective of test results.^ieng

Management of the adverse effects of antiretroviral therapy and medication adherence.

A commonly cited cause of poor adherence to highly active antiretroviral therapy (HAART) is adverse drug reactions. Short-term adverse effects are potential threats to successful introduction and maintenance of HAART. The long-term toxicities of HAART are still emerging and being defined, as evidenced by the recently described metabolic disorders (i.e., the syndrome of maldistribution, hyperlipemia, glucose intolerance and insulin resistance). With 14 licensed agents in 2000, other agents in common use, and numerous combinations of >/=3 drugs, awareness and recognition of adverse effects are increasingly important for clinicians and patients. The common adverse drug reactions encountered with HAART, including new agents and their impact on patient adherence, are reviewed. Current strategies to anticipate and mitigate adverse effects are summarized.

The effect of cooking processes on PCB levels in edible fish tissue.

A significant factor in estimating human intake of polychlorinated biphenyls (PCBs) from fish consumption is the loss of PCBs during cooking. The total amount of PCBs actually consumed in the cooked fish may be significantly lower than the PCB level present before cooking because lipids and lipophilic compounds like PCBs tend to be removed from the fish during cooking. Several studies investigating the extent of loss of PCB compounds during the cooking process have been published in the peer-reviewed literature. However, because of what is perceived as inconsistent and inadequate data on the removal of these compounds, federal and state regulators typically do not assume that cooking reduces contaminant levels (EPA, 1990; 1991). In this paper, an attempt was made to reduce the uncertainty in the findings of these studies on PCB losses during the cooking process. This was accomplished by (1) eliminating studies that lacked statistical power to determine the degree of reduction, (2) reporting all of the results in a common format, and (3) characterizing studies by cooking method. In addition, the studies that reported increases in PCB concentration after cooking were carefully reviewed to provide a possible explanation of this occurrence. Based upon this analysis, it was concluded that cooking processes such as baking, broiling, microwave cooking, poaching, and roasting remove approximately 20 to 30% of the PCBs. Frying appears to remove more than 50%. PCB cooking losses also appears to be a function of the initial lipid concentration in the fish. Based upon this analysis, it is clear that the information from these studies do provide a reasonable basis for federal and state regulators to permit a quantitative adjust of PCB intakes.

Quality measures in health care.

This article discusses measurement of quality in health care. The authors attempt to answer the following questions: why measure quality, and what will quality measurement do? The current quality measurement system is described including definitions of the measurable aspects of health care and current measurement tools. Finally, suggested benchmarks for various health care measurements are included.

Duodenal mucosal T cell subpopulation and bacterial cultures in acquired immune deficiency syndrome.

Enteric infections, chronic diarrhea frequently with no obvious etiology, and weight loss cause major morbidity and mortality in acquired immune deficiency syndrome (AIDS). Alterations in mucosal immunity may explain the increased incidence of enteric infections, and contamination of the upper small intestine with bacteria may be the cause of weight loss observed in these patients. To test this hypothesis we studied the mucosal T lymphocyte subset in duodenal mucosal biopsies in 14 AIDS and seven control patients. Duodenal fluid was also cultured for aerobic and anaerobic bacteria. There was a significant decrease among leu-3a T cells (helper/inducer) subset in AIDS. The proportion of mucosal T cells reacting with leu-2a (cytotoxic/suppressor) was significantly increased in AIDS patients. These patients also had a significant reversal of the normal mucosal helper/suppressor T cell ratio. There was no change in the number of leu-7 cells (cells mediate natural killer and antibody-dependent cellular cytotoxicity) as compared to controls. All patients with diarrhea and three of five patients without diarrhea had bacteria in their duodenal fluid. Mean number of organisms was 4.5 X 10(4)/ml. Cultures were negative in all control subjects. The results reveal that the abnormalities of T cell subpopulation in the blood of AIDS patients also occur in their duodenal mucosa. This immunological abnormality is associated with the bacterial colonization of upper gastrointestinal tract which may explain the diarrhea and weight loss observed in majority of our patients. The results also indicate that increased incidence of enteric infections in AIDS may be explained on the basis of altered mucosal immunity.

HIV and syphilis seroprevalence among clients with sexually transmitted diseases attending a walk-in clinic at Cook County Hospital.

BACKGROUND AND OBJECTIVES: To determine the HIV and syphilis seroprevalence in a patients with suspected sexually transmitted diseases at an urban walk-in clinic. METHODS: Between January and November 1991, 515 patients with suspected sexually transmitted diseases were simultaneously tested for syphilis and HIV antibodies. RESULTS: The cohort studied was young (85% were < 40 years), 81% were black, 11% Hispanic, and 71% reported heterosexual contact as the primary HIV risk factor. HIV seroprevalence was 8% (41/515), (95% confidence interval [95% CI], 5.66%, 10.34%). Syphilis seroprevalence rate was 21.4% (110/515), (95% CI 17.86%, 24.94%). Syphilis seroprevalence in those who were HIV positive was 31.7% (13/41), (95% CI 17.46%, 45.94%) as compared to 5.9% (28/574), (95% CI 3.78%, 8.02%) in those who were HIV negative. CONCLUSION: The HIV seroprevalence among patients with sexually transmitted diseases who are screened for syphilis was disturbingly high. Patients who were seropositive for HIV had a significantly higher rate of syphilis than those who were HIV negative.

CD4+ T lymphocyte counts and patterns of mortality among patients infected with human immunodeficiency virus who were enrolled in community programs for clinical research on AIDS.

CD4+ T lymphocyte measurements are used frequently in clinical practice and have important prognostic implications. In this study, we describe mortality patterns for 5,204 human immunodeficiency virus (HIV)-infected patients classified in different CD4+ cell strata; patients with and patients without a history of disease progression were included. Patients were enrolled in studies sponsored by the Terry Beirn Community Programs for Clinical Research on AIDS of the National Institute of Allergy and Infectious Diseases between September 1990 and December 1993. Over a median follow-up period of 23.6 months, 1,703 of the 5,204 patients died. For those with CD4+ cell counts (/mm3) of < 25, 25-49, 50-99, 100-199, and 200-499, the cumulative mortality rates after 24 months were 72%, 58%, 47%, 27%, and 10%, respectively. The median survival time was 15 months for those with CD4+ cell counts of < 25 cells/mm3; 21 months for those with CD4+ cell counts of 25-49 cells/mm3; and 40 months for patients with CD4+ cell counts of 100-199/mm3. In each CD4+ cell stratum, mortality rates were higher for those with a history of disease progression at entry into the study; across all CD4+ cell strata, mortality was 60% greater (relative risk = 1.6; 95% confidence interval = 1.5-1.8). These data should be useful in planning clinical trials, and they have implications in terms of the frequency with which CD4+ cell counts should be measured to monitor the progression of HIV infection.

HIV multidisciplinary teams work: support services improve access to and retention in HIV primary care.

The multidisciplinary team model of HIV care evolved out of necessity due to the diverse characteristics and needs of people living with HIV disease. Though it is now accepted as the international standard of care, it represents a significant departure from methods of care for other infectious diseases, and debate continues regarding the effectiveness of its interventions. The debate has been largely uninformed by data; for example, little is known about the relationship between ancillary support services and primary care outcomes. We hypothesized that support services increase access to and retention in HIV primary care in an inner city public hospital clinic. We conducted a retrospective analysis of clinical data sets on 2,647 patients at the CORE Center, Chicago from 1997-1998 to investigate the relationship between four support services-case management (CM), transportation (TRANS), mental health (MH) and chemical dependency (CD)-and access to and retention in HIV primary care. We found that patients who received each of these services were significantly more likely to receive any care, regular care and had more visits than patients with no service, and retention increased by 15-18%. Female gender, younger age, self-pay status and IDU predicted less regular care. Need for all services was substantial and significantly greater in women. Outcomes improved to the greatest extent among patients who needed and received each service. We conclude that support services significantly increased access to and retention in HIV primary care. Our findings validate the multidisciplinary team model of HIV care, and suggest that health services that are tailored to the express needs of patients lead to better care and improved health outcomes. Further testing of changes in health care delivery to meet the rapidly changing needs of people living with HIV disease and respond to the constantly changing practice of HIV medicine is urgently needed to maintain and extend the advances in HIV care outcomes of the past decade.

Survival and disease progression according to gender of patients with HIV infection. The Terry Beirn Community Programs for Clinical Research on AIDS.

OBJECTIVE: To compare disease progression and mortality between women and men infected with human immunodeficiency virus (HIV). DESIGN: Multicenter cohort. SETTING: Seventeen community-based centers participating in the Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA). PATIENTS: A total of 768 women and 3779 men enrolled in one or more of 11 protocols between September 7, 1990, and September 30, 1993. MAIN OUTCOME MEASURES: Survival and opportunistic events. RESULTS: The median CD4+ cell count at enrollment into the cohort was 0.240 x 10(9)/L (240/microL) for women and 0.137 x 10(9)/L for men (P < .001). Compared with men, women were younger (36 vs 38 years), more likely to be African American or Hispanic (78% vs 44%), and more likely to have reported a history of injection drug use (49% vs 27%). Women had been followed up for a median of 14.5 months and men for 15.5 months. The adjusted relative risk (RR) for death among women compared with men was 1.33 (95% confidence interval [CI], 1.06 to 1.67; P = .01) and for disease progression (including death) was 0.97 (95% CI, 0.82 to 1.15; P = .72). Women were at increased risk for bacterial pneumonia (RR, 1.38; 95% CI, 1.05 to 1.92) and at reduced risk for the development of Kaposi's sarcoma (RR, 0.16; 95% CI, 0.04 to 0.65) and oral hairy leukoplakia (RR, 0.54; 95% CI, 0.31 to 0.94). The increased risk of death and bacterial pneumonia for women compared with men was primarily evident among those with a history of injection drug use (RR, 1.68 for death, 95% CI, 1.20 to 2.35, P = .003; RR, 1.53 for bacterial pneumonia, 95% CI, 1.03 to 2.29, P = .04). Among patients without a history of disease progression at entry, death was the first event reported for more women than men (27.5% vs 12.2%). CONCLUSIONS: Compared with men, HIV-infected women in the CPCRA were at increased risk of death but not disease progression. Risks of most incident opportunistic diseases were similar for women and men; however, women were at an increased risk of bacterial pneumonia. These findings may reflect differential access to health care and standard treatments or different socioeconomic status and social support for women compared with men.