Intention to adhere to HIV treatment: a patient-centred predictor of antiretroviral adherence.

OBJECTIVES: Despite the effectiveness of highly active antiretroviral therapy (HAART), HIV remains a major cause of mortality in the USA, largely as a result of poor HIV treatment adherence. In this study we assessed the association between five patient-centred factors and adherence to HIV treatment. METHODS: We surveyed 244 adults at two HIV clinics in Houston, Texas between October 2009 and April 2010. Participants were given a questionnaire and their charts were reviewed for clinical data. Survey items assessed the following factors: self-assessed HIV knowledge, awareness of disease biomarkers, intention to adhere to HIV treatment, health literacy and decision-making style. The primary outcome measure was HAART adherence during the previous month. Logistic regressions were performed to calculate the effect of each factor on adherence. RESULTS: All participants had HIV/AIDS and were on HAART at enrolment. Eight per cent of participants were female, 57% were African-American and 16% were Hispanic. Mean age was 58.1 years. Sixty-eight per cent were adherent to HAART during the last month. On univariate analysis, a preference for wanting choices, correct knowledge of recent HIV viral load level, and intention to adhere to HIV treatment were significantly associated with adherence. On multivariate analysis, only intention to adhere to HIV treatment remained statistically significant after adjusting for other factors (odds ratio 2.2; 95% confidence interval 1.1 to 4.3). CONCLUSIONS: Intention to adhere to HIV treatment was significantly associated with self-reported adherence to HAART. Interventions that bolster patients' intentions to adhere to HIV treatment during clinical encounters may improve adherence to HAART and HIV control.

Pseudomonas aeruginosa: growth in distilled water from hospitals.

Pseudomonas aeruginosa can grow relatively fast in distilled water obtained in hospitals and achieve high cell contaminations which remain stable for long periods of time. Cells grown in distilled water react quite differently to chemical and physical stresses than cells grown in standard laboratory culture media.

Outbreak of pyrogenic reactions at a dialysis center. Association with infusion of heparinized saline solution.

Twenty-three pyrogenic reactions occurred in 16 patients undergoing hemodialysis at a private dialysis center in the south central United States between November 23 and December 2, 1978. No deaths were attributed to reactions; however, 10 patients were hospitalized for observation after experiencing a reaction. Cultures of all blood specimens obtained from the patients gave negative results. Chills (75 percent), nausea and/or vomiting (30 percent), and fever (90 percent) were the most common signs and symptoms, with mean times of onset after starting dialysis of 1.1, 1.6, and 3.6 hours, respectively. An epidemiologic and laboratory investigation documented that reactions occurred only in patients who had anticoagulation with a dilute solution of heparin. Analyses of heparinized saline solution used during the outbreak revealed a bacterial count of 7.4 X 10(5)/ml and a bacterial endotoxin level of 1,300 ng/ml. Acinetobacter calcoaceticus var. Iwoffi was isolated from the solution. Diluted heparin solution was prepared at the dialysis center by adding commercially supplied sodium heparin to 0.9 percent sodium chloride infusion fluid. Bacteria and endotoxin were not detected in vials of stock heparin and bags of unopened 0.9 percent sodium chloride infusion fluid. We concluded that contamination of the solution occurred at the dialysis center. After changes in the preparation and use of heparin were instituted on December 4, 1978, no pyrogenic reactions occurred in more than 400 subsequent dialyses.

Effects of vesnarinone on peripheral circulating levels of cytokines and cytokine receptors in patients with heart failure: a report from the Vesnarinone Trial.

STUDY OBJECTIVES: Proinflammatory cytokines may contribute to disease progression in heart failure by virtue of the direct toxic effects that these molecules exert on the heart and the circulation. Accordingly, there is interest in developing therapeutic agents with anticytokine properties that might be used as adjunctive therapy to modulate proinflammatory cytokine levels in patients with heart failure. Previous experimental studies suggested that vesnarinone has potent anticytokine properties in vitro. Therefore, we examined the effects of vesnarinone on circulating levels of cytokines and cytokine receptors in a large-scale, multicenter, clinical trial of patients with moderate-to-advanced heart failure: the Vesnarinone Trial (VEST). METHODS: Circulating levels of tumor necrosis factor (TNF)-alpha, soluble TNF-receptor type 1, soluble TNF-receptor type 2, as well as interleukin (IL)-6 and soluble IL-6 receptor (sIL-6R) were measured on plasma samples by enzyme-linked immunosorbent assay at baseline and at 24 weeks in patients who were receiving placebo (n = 352), 30 mg of vesnarinone (n = 367), and 60 mg of vesnarinone (n = 327). RESULTS: Treatment with 30 mg and 60 mg of vesnarinone had no effect on circulating levels of cytokines or cytokine receptors in patients with advanced heart failure over a 24-week period. CONCLUSIONS: In contrast to the potent anticytokine effects observed with vesnarinone in experimental studies in vitro, the results of this clinical study suggest that vesnarinone does not have any measurable anticytokine effects in vivo in patients with moderate-to-advanced heart failure.

An assessment of the airborne route in hepatitis B transmission.

The experimental and epidemiologic evidence for airborne transmission of hepatitis B is inconclusive and our efforts to detect airborne HBsAg or blood in environments where hepatitis B transmission occurs have been uniformly unsuccessful. In the specific areas investigated: dialysis centers, laboratories, and dental operatories, other major routes of transmission that can explain the spread of hepatitis B invariably are present. Therefore, while airborne taansmission is theoretically possible and probably has occurred, at this time its contribution to the overfall hepatitis B problem cannot be quantitated. we fell comfortable in concluding that airborne HBV does not play a major role in hepatitis B transmission and that true airborne infections are probably rare. Because of the fine line airborne transmission from contract transmission via droplets, we feel it important to emphasize the need to take those precautions that protect against the latter. These include the use of gloves where surfaces become contaminated and masks and glasses to protect the eyes, nose and mouth where the possibility of spatter exists.

The hospital multistay rate as an indicator of quality of care.

OBJECTIVES: To evaluate the hospital multistay rate to determine if it has the attributes necessary for a performance indicator that can be applied to administrative databases. DATA SOURCES/STUDY SETTING: The fiscal year 1994 Veterans Affairs Patient Treatment File (PTF), which contains discharge data on all VA inpatients. STUDY DESIGN: Using a retrospective study design, we assessed cross-hospital variation in (a) the multistay rate and (b) the standardized multistay ratio. A hospital's multistay rate is the observed average number of hospitalizations for patients with one or more hospital stays. A hospital's standardized multistay ratio is the ratio of the geometric mean of the observed number of hospitalizations per patient to the geometric mean of the expected number of hospitalizations per patient, conditional on the types of patients admitted to that hospital. DATA COLLECTION/EXTRACTION METHODS: Discharge data were extracted for the 135,434 VA patients who had one or more admissions in one of seven disease groups. PRINCIPAL FINDINGS: We found that 17.3 percent (28,300) of the admissions in the seven disease categories were readmissions. The average number of stays per person (multistay rate) for an average of seven months of follow-up ranged from 1.15 to 1.45 across the disease categories. The maximum standardized multistay ratio ranged from 1.12 to 1.39. CONCLUSIONS: This study has shown that the hospital multistay rate offers sufficient ease of measurement, frequency, and variation to potentially serve as a performance indicator.

Rates of health services utilization and survival in patients with heart failure in the Department of Veterans Affairs medical care system.

The objective of this study was to describe patterns of hospital and clinic use and survival for a large nationwide cohort of patients with heart failure. A retrospective cohort study of patients treated in the Veterans Affairs medical care system was conducted using linked administrative databases as data sources. In 1996, the average heart failure cohort member had 1-2 hospitalizations, 14 inpatient days, 6-7 visits with the primary physician, 15 other visits for consultations or tests, and 1-2 urgent care visits per 12 months. The overall risk-adjusted 5-year survival rate was 36%. Hospital use rates in the cohort fell dramatically between 1992 and 1996. One-year survival rates increased slightly over the period. Patients with heart failure are heavy users of services and have a very poor prognosis. Utilization and outcome data indicate the need for major efforts to assure quality of care and to devise innovative ways of delivering comprehensive services.

Air sampling for hepatitis B surface antigen in a dental operatory.

Forty samples of air with a mean sample volume of 104 liters were collected during the treatment of patients whose blood was positive for HBsAG: no samples contained HBsAG and occult blood. These findings suggest that, if environmentally mediated transmission of hepatitis B occurs in the dental operatory, it is more likely to occur through contact with contaminated surfaces than through the airborne route.

A case-control study of lung cancer mortality in four rural Arizona smelter towns.

To investigate factors related to lung cancer mortality in four Arizona copper-smelter towns, the authors identified 142 lung cancer cases and 2 matched controls per case from decedent residents during 1979-1990. The authors obtained detailed information on lifetime residential, occupational, and smoking histories via structured telephone interviews with knowledgeable informants. The authors linked estimated historical environmental exposures to smelter emissions (based on atmospheric diffusion modeling of measured sulfur dioxide concentrations) with residential histories to derive individual profiles of residential exposure. The results of this study provided little evidence of a positive association between lung cancer and residential exposure to smelter emissions. Conditional logistic regression analysis revealed a statistically significant positive association between lung cancer and reported employment in copper mines and/or smelters, although specific factors associated with the apparently increased risk among these workers could not be identified in this community-based study.

Effect of social support on informed consent in older adults with Parkinson disease and their caregivers.

PURPOSE: To evaluate the effects of social support on comprehension and recall of consent form information in a study of Parkinson disease patients and their caregivers. DESIGN AND METHODS: Comparison of comprehension and recall outcomes among participants who read and signed the consent form accompanied by a family member/friend versus those of participants who read and signed the consent form unaccompanied. Comprehension and recall of consent form information were measured at one week and one month respectively, using Part A of the Quality of Informed Consent Questionnaire (QuIC). RESULTS: The mean age of the sample of 143 participants was 71 years (SD = 8.6 years). Analysis of covariance was used to compare QuIC scores between the intervention group (n = 70) and control group (n = 73). In the 1-week model, no statistically significant intervention effect was found (p = 0.860). However, the intervention status by patient status interaction was statistically significant (p = 0.012). In the 1-month model, no statistically significant intervention effect was found (p = 0.480). Again, however, the intervention status by patient status interaction was statistically significant (p = 0.040). At both time periods, intervention group patients scored higher (better) on the QuIC than did intervention group caregivers, and control group patients scored lower (worse) on the QuIC than did control group caregivers. IMPLICATIONS: Social support played a significant role in enhancing comprehension and recall of consent form information among patients.

Design and modification of the day care environment.

Transmission of infectious disease in day care centers may be influenced by the design, construction, and maintenance of the physical environment. Microbiologic studies of the day care environments showed that bacteria of fecal origin were frequently present on the hands of children and staff members, on environmental surfaces, and in air. In all three types of samples, the prevalence of fecal contamination was inversely related to the age of the children associated with the source of the samples. The high proportion of children in diapers and staff members whose hands were contaminated was of particular concern from the standpoint of disease transmission. These findings suggested that readily available hand-washing facilities; segregation of infants, toddlers, and older children; and wash-ability of surfaces were factors that might reduce the role of environmental contamination in the transmission of disease in day care centers. Centers incorporating these suggestions have been designed and constructed. Particular attention was devoted to design concepts and the selection of surface materials for such critical locations as kitchens, toilets areas, and diaper-changing areas.

Photoreactivation of Pseudomonas cepacia after ultraviolet exposure: a potential source of contamination in ultraviolet-treated waters.

Cells of a naturally occurring strain of Pseudomonas cepacia grown in distilled water were exposed to ultraviolet radiation. Irradiated samples incubated on membrane filters or in fluid recovery media in the absence of light showed no evidence of dark repair mechanisms. When samples were exposed to fluorescent light ranging from 50 to 950 foot candles (538 to 10,222 lux) of illumination, apparent photo-induced repair of ultraviolet injury resulted in 1- to 4-log increases in viable cells recovered.

Microbiological evaluation of the vacuum probe surface sampler.

The development of the vacuum probe, a new device for surface sampling, was recently reported. The original technique was slightly modified and a microbiological evaluation was conducted. The probe proved to be an effective sampling device, removing 98% and recovering 88% of surface contaminants resulting from the accumulation of airborne microorganisms. The probe was decidedly less effective in removing and recovering handling contamination than fallout contamination. There was also evidence that certain microorganisms could not survive prolonged exposure to airflow in the probe. However, the vacuum probe procedure recovered twice as many microorganisms as did the swab-rinse technique when compared directly.

Recommendations for the care of automated peritoneal dialysis machines: can the risk of peritonitis be reduced?

Automated peritoneal dialysis systems have helped make intermittent peritoneal dialysis an alternative to hemodialysis for long-term management of patients with end-stage renal disease. However, if not cleaned and maintained properly, these machines provide a reservoir for pathogens. The microbiologic barriers in these machines are not impenetrable, but sterile dialysate fluid can be produced if the machines are adequately cleaned and disinfected. Potential shortcomings of the microbiologic barriers are discussed, and guidelines to prevent contamination of the internal parts of a machine are suggested.

Viral hepatitis B: aspects of environmental control.

In recent years it has become increasingly evident that viral hepatitis type B is a major disease problem among patients and/or health professionals associated with environments such as hemodialysis centers, dental operatories, clinical laboratories, and institutions for the mentally retarded. Studies have incriminated the intramural environment as well as specialized equipment and procedures as important factors in disease transmission. With hepatitis B surface antigen (HBsAg) as a marker of potentially infectious blood or body fluids such as saliva, it is possible to assess the environmental role in transmission of hepatitis B by use of a swab-rinse technique coupled with radioimmune assay. Assay procedures have been developed and utilized for detecting HBsAg on surfaces and in air and for quantitating of HBsAg in thermal and chemical inactivation studies. Specific decontamination strategies and recommendations for sterilization or disinfection procedures are described.

Use of ultrasonic energy in assessing microbial contamination on surfaces.

Ultrasonic tanks were evaluated for their ability to remove viable microorganisms from various surfaces for subsequent enumeration. Test surfaces were polished stainless steel, smooth glass, frosted glass, and electronic components. The position of contaminated surfaces in relation to the ultrasonic energy source, distance of the ultrasonic source from the test surfaces, and temperature of the rinse fluid were some of the factors which influenced recovery. Experimental systems included both naturally occurring microbial contamination and artificial contamination with spores of Bacillus subtilis var. niger. The results showed that ultrasonic energy was more reliable and efficient than mechanical agitation for recovering surface contaminants. Conditions which increased the number and percentage of microorganisms recovered by ultrasonic energy were: using a cold rinse fluid, placing the sample bottle on the bottom of the ultrasonic tank, and facing the contaminated surfaces toward the energy source. It was also demonstrated that ultrasonic energy could be effectively used for eluting microorganisms from cotton swabs.

Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes.

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) tube placement is the preferred method for long-term enteral feeding of patients who are unable to take food by mouth. Despite the widespread acceptance of the procedure, no large-scale study of the long-term outcomes of patients receiving PEG tubes has been reported. The objective of this study was to determine the survival of patients in whom PEG tubes are placed. DESIGN: Retrospective cohort study using data obtained from two computerized databases. SETTING: Department of Veterans Affairs hospitals. PATIENTS: Seven thousand three hundred sixty-nine patients who received a PEG tube in fiscal years 1990 through 1992. RESULTS: For the 7,369 patients, the mean age was 68.1 years and 98.6% were men. PEG tubes were most commonly places in patients with cerebrovascular disease (18.9%), other organic neurologic disease (28.6%), or head and neck cancer (15.7%). Although the complication rate of the procedure itself was low (4%), because of the severity of their underlying disease, 1,732 patients (23.5%) died during the hospitalization in which the PEG tube was placed. The median survival of the full cohort was 7.5 months. CONCLUSIONS: This study documents the widespread placement of PEG tubes in severely ill patients, half of whom are in the terminal phase of their illness. Further study is needed to determine whether these patients benefit from PEG tube placement in terms of their quality of life and survival.

Relative frequency distribution of d(125 C) values for spore isolates from the mariner-Mars 1969 spacecraft.

Bacterial spore crops were prepared from 103 randomly selected aerobic mesophilic isolates collected during a spore assay of Mariner-Mars 1969 spacecraft conducted by the Jet Propulsion Laboratory. D(125 c) values, which were determined by the fractional-replicate-unit-negative-most-probable number assay method using a forced air oven, ranged from less than 5 min to a maximum of 58 min. Subsequent identification of the 103 isolates indicated that there was no relationship between species and dry-heat resistance. A theoretical dry-heat survival curve of the "population" was nonlinear. The slope of this curve was determined almost exclusively by the more resistant organisms, although they represented only a small portion of the "population."

Factors affecting comparative resistance of naturally occurring and subcultured Pseudomonas aeruginosa to disinfectants.

A strain of Pseudomonas aeruginosa was isolated in pure culture from the reservoir of a hospital mist therapy unit by an extinction-dilution technique; its natural distilled water environment was used as a growth and maintenance medium. After a single subculture on Trypticase soy agar, the strain showed a marked decrease in resistance to inactivation by acetic acid, glutaraldehyde, chlorine dioxide, and a quaternary ammonium compound when compared with naturally occurring cells grown in mist therapy unit water. The following factors were observed to affect the relative resistances of naturally occurring and subcultured cells of the P. aeruginosa strain: (i) temperature at which the cultures were incubated prior to exposure to disinfectants, (ii) growth phase of the cultures at the time of exposure to disinfectants, (iii) nature of the suspending menstruum for disinfectants, and (iv) exposure to fluorescent light during incubation of inocula prior to testing. The applied significance of these findings may alter the present concepts of disinfectant testing as well as routine control procedures in the hospital environment.