The associations of CD4 count, CD4/CD8 ratio, and HIV viral load with survival from non-small cell lung cancer in persons living with HIV.

HIV status may influence survival from non-small cell lung cancer (NSCLC). Among NSCLC patients in the Bronx, NY, we assessed (1) associations of CD4 count, CD4/CD8 ratio and HIV viral load (VL) with survival and (2) prognostic factors among persons living with HIV (PLWH). We compared survival from NSCLC diagnosis (2004-2017) between HIV-negative persons (HIV-, n=2,881) and PLWH (n=88) accounting for clinical and sociodemographic factors. HIV-survival was also compared with PLWH, dichotomized by CD4 (<200 vs. ≥200cells/µL), CD4/CD8 (median, <0.43 vs. ≥0.43) and VL (<75 vs. ≥75copies/mL) at NSCLC diagnosis. Among PLWH, we assessed the relationships of CD4, CD4/CD8, and VL with survival, adjusting for age, sex, and cancer stage. PLWH with CD4< 200cells/µL had lower survival than HIV- [hazard ratio, 95% confidence interval [HR(95%CI)]=1.86(0.98-3.55)]. Survival was similar between PLWH with CD4≥ 200cells/µL and HIV- [HR(95%CI) = 0.90(0.61-1.33)]. Results were similar when categorizing PLWH by CD4/CD8 [vs. HIV-: low CD4/CD8: HR(95%CI) = 1.74(1.07-3.89); high CD4/CD8: HR(95%CI) = 0.63(0.37-1.07)] and VL [vs. HIV-: <75copies/mL: HR(95%CI) = 0.74(0.46-1.21), ≥75copies/mL: HR(95%CI) = 1.41(0.88-2.27)]. Among PLWH, CD4< 200cells/µL was associated with worse survival [vs. CD4≥ 200cells/µL: HR(95%CI) = 2.37(1.14-4.92)]. CD4, CD4/CD8, and VL may be prognostic markers for PLWH with NSCLC, suggesting immune status may be important in NSCLC survival among PLWH.

Woodland caribou calving fidelity: Spatial location, habitat, or both?

Individuals that isolate themselves to give birth can use more than one strategy in choosing birth sites to maximize reproductive success. Previous research has focused on the consistency in the use of the same birth-site across years (i.e., spatial fidelity), but individuals alternatively may use similar habitat conditions across years (i.e., habitat fidelity). Using GPS telemetry, we determined whether woodland caribou expressed spatial or habitat fidelity during calving, and evaluated intrinsic and extrinsic factors associated with expressing either type of fidelity. We identified 56 individuals with ≥2 putative birth events, via a movement-based model, across northern Ontario between 2010 and 2014. Individuals were classified as expressing (1) spatial fidelity by comparing sequential calving locations to a random spatial distribution of available calving locations, (2) habitat fidelity using a logistic use model compared to a null (intercept only) model, (3) no fidelity (neither criterion met), or (4) both spatial and habitat fidelity (both criteria met). Across all individuals, 37% expressed no fidelity (36 of 98), 15% expressed only spatial fidelity (15 of 99), 35% expressed only habitat fidelity (34 of 98), and 14% expressed both spatial and habitat fidelity (14 of 98). Older individuals were more likely to express spatial fidelity, whereas lower availability of upland and lowland conifer forests without linear features increased the probability an individual expressed habitat fidelity. Our results indicate that managing for caribou calving needs to consider protecting both specific, known birthing sites, but also broad-scale areas of preferred habitat for calving. Understanding the mechanisms that influence caribou expressing calving fidelity, and associated fitness costs, is crucial for the conservation of the species.

Pneumocystis jirovecii prophylaxis discontinuation based upon total lymphocyte count in HIV-infected adults treated with antiretroviral therapy.

Pneumocystis jirovecii pneumonia (PCP) prophylaxis may be discontinued when CD4 is > or =200 cells/mm(3) for three months in response to highly active antiretroviral therapy (HAART). Unlike CD4, the total lymphocyte count (TLC) is inexpensive and widely available in resource-constrained countries. Paired TLC and CD4 values of HIV-infected patients attending an HIV clinic from 1998 to 2005 were analysed by Spearman's correlation. The sensitivity, specificity, positive predictive value, negative predictive value and receiver operating characteristics (ROC) using TLC cut-off points between > or =1400 and > or =2000 cells/mm(3) to predict CD4 > or =200 cells/mm(3) were calculated. Next, a cohort of patients who had a TLC < or = 1200 cells/mm(3) and subsequently achieved various TLC cut-off points sustained over three months while receiving HAART was identified. Subjects with subsequent CD4 > or =200 cells/mm(3) in response to HAART were considered to have negligible risk for PCP. There was significant correlation between TLC and CD4 in 46,250 observations from 4307 individuals (r = 0.695, P < or = 0.001). The area under the ROC curve was 0.85 (95% CI = 0.85-0.86). In the historical cohort analysis, 85% and 70% of subjects who achieved TLC > or = 2000 cells/mm(3) and > or =1400, respectively, had a corresponding CD4 > or = 200 cells/mm(3). A sustained rise in TLC in response to HAART may potentially serve as a criterion for discontinuing PCP prophylaxis in resource-constrained countries.

Multiple antibiotic changes during the first 72 hours of hospitalization.

BACKGROUND: Increasing concern about inappropriate antibiotic use prompted us to examine whether our patients were receiving frequent and perhaps unwarranted changes of antibiotic therapy. METHODS: We evaluated antibiotic prescribing by the physicians in the Emergency Department and by those on the inpatient medical service during the first 72 hours of hospitalization in 119 patients admitted with suspected serious infections to an acute care, university-affiliated, municipal teaching hospital. The appropriateness of antibiotic prescriptions was assessed independently and retrospectively by 2 infectious disease specialists (each based at a different hospital) using a 4-grade scale (from 1 = wrong choice to 4 = appropriate). Of their evaluations of the 427 antibiotic regimens given to the 119 patients during 4 defined intervals during their first 72 hours of hospitalization, 90% agreed with each other within 1 grade. Their evaluations were then compared with the selections that had been made at each interval by the prescribing physicians. RESULTS: Successive prescribing physicians changed the antibiotic regimens in 77% of cases during the first 24 hours and in 56% during the next 48, often without apparent clinical or microbiologic indications. By 72 hours, the 119 patients had received a mean of 3.1 +/- 1.3 (+/-SD) different antibiotics, and 40 received between 4 and 7. Only 7% of the patients had no change in the regimen prescribed originally. CONCLUSIONS: Many patients had multiple changes of antibiotics, often unnecessarily, resulting in exposure to too many agents.

Prevalence and predictive value of overweight in an urban HIV care clinic.

OBJECTIVE: To determine the prevalence and predictive value of overweight in an urban HIV clinic. METHODS: Medical records of all new adult, nonpregnant registrants in 1996 in an urban HIV clinic with at least one height and weight measurement were reviewed. Body mass index (BMI) at clinic enrollment was calculated, and prevalence of overweight was thus determined. The subsequent clinical course of the overweight group was compared with that of a randomly selected group of gender-stratified non-overweight patients. RESULTS: At baseline, 12.6% of men and 32.5% of women were overweight. Female gender and lack of AIDS diagnosis were independently associated with overweight. More than one half of women and 19.6% of men were overweight at some point during the study. Providers were more likely to properly acknowledge underweight than overweight. Among patients without AIDS, there was a trend toward slower disease progression and lower viral load in overweight patients, despite similar baseline CD4+ lymphocyte counts and similar time to initiation of highly active antiretroviral therapy. In multivariate proportional hazards analyses, lower baseline BMI and falling BMI during follow-up were independently predictive of progression to AIDS. CONCLUSIONS: Overweight was a common and underrecognized finding, particularly among women. Overweight patients may progress more slowly to AIDS than non-overweight patients.

Staphylococcus aureus binding to human nasal mucin.

Colonization of human nasal mucosa with Staphylococcus aureus sets the stage for subsequent systemic infection. This study characterizes S. aureus adhesion to nasal mucosa in vitro and investigates the interaction of S. aureus with human nasal mucin. S. aureus binding to cell-associated and cell-free mucus was greater than to nonmucin-coated epithelial cells. Scanning electron microscopy of S. aureus incubated with human nasal mucosal tissue showed minimal binding to ciliated respiratory epithelium. In a solid-phase assay, S. aureus bound to purified human nasal mucin-coated wells significantly more than to bovine serum albumin-coated microtiter wells. Binding to mucin was saturable in a dose- and time-dependent fashion. Staphylococcal adherence to human nasal mucin was inhibited by bovine submaxillary mucin but not by fibrinogen. Pretreatment of mucin with periodate but not with pronase reduced adherence. Trypsin treatment of the bacteria significantly reduced adherence to mucin. 125I-labelled nasal mucin bound to two surface proteins (138 and 127 kDa) of lysostaphin-solubilized S. aureus. Binding to human nasal mucin occurs in part via specific adhesin-receptor interactions involving bacterial proteins and the carbohydrate moiety in mucin. These experiments suggest that S. aureus binding to mucin may be critical for colonization of the nasopharyngeal mucosa.

Rates of and factors associated with self-reported prior HIV testing among adult medical patients in an inner city emergency department in the Bronx, New York City.

We studied the rates of and factors associated with self-reported prior human immunodeficiency virus (HIV) testing in adult patients visiting an emergency department (ED) in the Bronx, New York City. A total of 1,744 consecutive noncritical adult medical emergency patients responded to a standardized interview administered by ED physicians. The interview included questions pertaining to demographic characteristics, prior HIV testing, and HIV risk behaviors. On multivariate analysis, female gender, younger age, history of weight loss, injecting drug use (IDU), syphilis, and genital herpes were all associated with increased reported prior testing rates. Race (i.e., black race) was an independent predictor of increased rates among male subjects; comparatively low rates were reported by patients with a first language other than English, patients lacking medical insurance, and highly sexually active, nonblack men. Increased HIV testing rates were reported by subjects with recognized HIV risk behaviors in a New York City ED population; however, substantial proportions of subjects at risk had not been tested. Programs of HIV testing and counseling need to include older, uninsured, and non-English-speaking segments of the population who engage in high-risk behaviors.

Factors associated with unrecognized HIV-1 infection in an inner-city emergency department.

STUDY OBJECTIVE: To determine the prevalence of and risk factors associated with unrecognized HIV-1 infection among medical patients presenting to an inner-city emergency department. METHODS: We conducted anonymous HIV-1 testing in subjects interviewed for risk behaviors and knowledge of HIV status at an inner-city ED in the Bronx, New York. Our subjects were consecutive adult medical patients in noncritical condition (N = 1,744) who were evaluated by three physicians providing primary emergency care. Each patient was given a structured interview for demographic characteristics, risk behaviors, and knowledge of HIV status. Excess serum, drawn for clinical purposes, was linked without identifiers to responses and tested for antibodies to HIV-1. In subjects who denied HIV infection, we tested associations with seropositivity using univariate analyses and logistic-regression techniques (multivariate). RESULTS: Of the 1,744 patients interviewed, 656 (37.6%) reported HIV risk behaviors. Of 970 tested for HIV-1 antibodies, 125 (12.9%) were seropositive. The prevalence of HIV-1 infection among those who denied known infection was 4.0% (35 of 875). In the multivariate model, independent predictors of unrecognized HIV-1 infection were age 35 to 44 years, crack cocaine use, history of syphilis, and ED diagnosis of an infection not necessarily related to HIV infection. Unrecognized HIV-1 infection was more likely among patients admitted to the hospital, but 21 of the 35 with unrecognized infection (60%) were not admitted and in 9(25.7%) no risk factors were identified. CONCLUSION: More than one third of patients who visited one inner-city ED acknowledged HIV risk behaviors. One quarter of patients with unrecognized HIV-1 infection reported no identifiable risk factors. Easily accessible HIV counseling and testing should be considered in EDs in areas serving persons at risk for HIV infection.

Rates of and risk factors for trichomoniasis among pregnant inmates in New York City.

BACKGROUND: Trichomonas vaginalis is a common pathogen that is associated with adverse pregnancy outcomes and may serve as a cofactor in human immunodeficiency virus (HIV) transmission. GOAL: To define the epidemiology of trichomoniasis in a population of newly incarcerated pregnant women in New York City. STUDY DESIGN: Prospective study of 213 pregnant prisoners attending prenatal clinic. Patients participated in an interview regarding sexual and drug-related behaviors, and underwent direct culture for T. vaginalis in addition to routine testing for syphilis, gonorrhea, and chlamydia. RESULTS: The prevalence of trichomoniasis was 46.9%. On univariate analysis, there was a significant association between trichomoniasis and older age, crack use, prostitution, known HIV infection, and positive serological test for syphilis. Multivariate analysis showed a significant association of trichomoniasis with crack use and positive serological test for syphilis. CONCLUSION: Trichomoniasis is highly prevalent in pregnant prisoners in New York City. The extent of disease observed may justify a formal program of testing and treatment and emphasizes the urgent need for harm reduction education and expanded HIV counseling and testing services in this high-risk population.

The pharmacoeconomic impact of antimicrobial therapy for peptic ulcer disease in a large urban jail.

PURPOSE: To determine the pharmacoeconomic impact of antimicrobial treatment of peptic ulcer disease (PUD) in a large urban jail. PATIENTS AND METHODS: Retrospective comparison of PUD-related pharmacy and laboratory expenditures over a 2-year period before and after the institution of a PUD treatment protocol with the priority of Helicobacter pylori eradication for inmates in Rikers Island Correctional Facility. RESULTS: After the protocol was adopted, total pharmacy-related and laboratory-related expenses for PUD care decreased by 40.2%, and expenditures for ranitidine declined by 52.2%. There was an increase in spending for antimicrobial agents and H. pylori antibody testing, but this was insignificant compared to the savings generated by decreased ranitidine usage. Annual savings in our facility as a result of this intervention were $123,449. CONCLUSIONS: Modern therapeutic strategies for PUD aimed at eradicating H. pylori can result in significant savings in the institutional setting; these savings are largely attributable to the decreased usage of histamine-2 receptor antagonists.

Gender differences in HIV risk behaviors in an adult emergency department in New York City.

BACKGROUND: The human immunodeficiency virus (HIV) epidemic in the US increasingly involves urban heterosexual adults, particularly women, belonging to ethnic minority groups. An understanding of gender-based differences in HIV risk behaviors within these groups would be of value in the ongoing struggle to limit HIV transmission in metropolitan centers. METHODS: This was a prospective study of demographic and historical characteristics and HIV risk behaviors. The study utilized a structured interview format, which was administered to all patients treated by participating emergency department physicians. RESULTS: On univariate analysis of data obtained from 1,460 patients who had neither a known HIV infection nor a chief complaint or final emergency department diagnosis associated with HIV risk behaviors, men were more likely to be older, homeless, to have ever injected drugs, used crack, engaged in same-gender sex, paid for sex, been incarcerated, or had syphilis or gonorrhea. Women were more likely to report prior chlamydia infection or to report that their sole sex partners had other partners within the past year. On multivariate analysis, variables independently associated with male gender included homelessness, injection drug use, crack use, any prior sexually transmitted disease (in subjects 35 years of age or older), and sex with prostitutes. In a separate analysis of patients admitting to drug use, the male predominance of other risk behaviors was not observed; the only significant differences between genders were a higher rate of prostitution among women and a higher rate of sexual contact with a prostitute among men. CONCLUSIONS: In patients visiting an inner-city emergency department in the Bronx, HIV risk behaviors are generally more common in men, but rates of risk behaviors among male and female drug users are comparable.