Thromboprophylaxis adherence to the ninth edition of American college of chest physicians antithrombotic guidelines in a tertiary care centre: a cross-sectional study.

RATIONALE: Venous thromboembolic disease is a source of significant morbidity in hospitalized patients. The American College of Chest Physicians published the ninth edition of antithrombotic therapy and prevention guidelines (AT9) in 2012, addressing thromboprophylaxis in hospitalized patients. A notable difference from previous guidelines was utilization of risk assessment models for thrombosis and bleeding to classify patients into risk categories. AIM: This study's objective was to evaluate thromboprophylaxis adherence to AT9 guidelines in a population of patients at the Centre intégré universitaire de santé et de service sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke. METHOD: A cross-sectional study at the Centre intégré universitaire de santé et de service sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke was performed between June and December 2012. Patients' risk factors for thrombosis and bleeding, and thromboprophylaxis use were documented. The Padua and Caprini models were used to determine thrombotic risk, and the International Medical Prevention Registry on Venous Thromboembolism bleeding risk score was used for bleeding risk. RESULTS: A total of 290 patients were included for analysis. Overall, 200 patients (70%) received some form of thromboprophylaxis. However, according to AT9 guidelines, only 162 patients (55.9%) received recommended prophylaxis, 91 (31.4%) had overuse of prophylaxis and 37 (12.7%) had underuse of prophylaxis. Appropriate prophylaxis use was higher in surgical (61.8%) than in medical (46.7%) patients. CONCLUSIONS: There was a high rate of inappropriate thromboembolic prophylaxis in our centre according to AT9 guidelines, mostly from overuse of prophylaxis. Utilization of risk assessment models in AT9 guidelines adds to the complexity of physician's decisions to prescribe thromboprophylaxis and needs further validation.

Comparison of the short-term efficacy and tolerability of lovastatin and pravastatin in the management of primary hypercholesterolemia.

Few data are available on the relative efficacy and tolerability of lovastatin and pravastatin, two 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, currently available in North America for treatment of hypercholesterolemia. The recommended starting dose is 20 mg QD with the evening meal for lovastatin. The recommended starting dose is 10 mg or 20 mg once daily at bedtime for pravastatin. In a double blind, double placebo, multicenter, randomized study, we compared the changes in plasma lipids and apolipoproteins in 217 patients with primary hypercholesterolemia treated for eight weeks with lovastatin 20 mg QD to pravastatin 10 mg QD or pravastatin 20 mg QD. The reductions in total cholesterol (TC) (21%), low-density lipoprotein cholesterol (LDL-C) (28%), and apolipoprotein B (apo B) (22%) were comparable for the lovastatin 20-mg and pravastatin 20-mg groups. Lovastatin 20 mg QD was significantly more effective than pravastatin 10 mg QD in lowering TC and LDL-C after four weeks of therapy and in the reduction of apo B after four and eight weeks of therapy. At the end of eight weeks of therapy, the mean reductions in TC and LDL-C were numerically greater with lovastatin 20 mg QD compared with pravastatin 10 mg QD, but the differences were not statistically significant. At the end of eight weeks, there was no difference between pravastatin 20 mg and pravastatin 10 mg in lowering TC and LDL-C. The frequency of overall side effects, including central nervous system-related symptoms and headache, was similar and low in all groups.

Risk of AIDS for recipients of blood components from donors who subsequently developed AIDS.

Reported cases of acquired immunodeficiency syndrome (AIDS) in San Francisco as of March 31, 1986, include 92 individuals who had donated blood subsequent to 1978. Their donated blood components had been transfused into 406 different recipients. The current status of 336 of these recipients was ascertained as of April 1, 1986. Of these, 223 had died at the time of our first contact, almost all as a result of the condition for which they were transfused. Seven had developed AIDS; five of these died, two before entry into the study and three subsequently. Forty-six additional living recipients were interviewed and evaluated. Seven had the AIDS-related complex, 18 had antibody to the human immunodeficiency virus (HIV) but were otherwise healthy, and 19 had no detectable anti-HIV. Two had risk factors other than transfusion. The frequency of infection of the recipient decreased as the time interval between transfusion and the diagnosis of AIDS in the donor increased. This information should be useful when counseling patients who have been transfused with blood components from donors later found to be infected with HIV.

Tuberculosis in patients with the acquired immunodeficiency syndrome. Clinical features, response to therapy, and survival.

Tuberculosis has been reported previously in patients with acquired immunodeficiency syndrome who are at increased risk of prior infection with Mycobacterium tuberculosis. We performed a population-based study of AIDS and tuberculosis in San Francisco using the Tuberculosis and AIDS Registries of the San Francisco Department of Public Health. Of 287 cases of tuberculosis in non-Asian-born males 15 to 60 yr of age reported from 1981 through 1985, 35 (12%) also had AIDS, including 23 American-born whites. Patients with tuberculosis and AIDS were more likely to be nonwhite and heterosexual intravenous drug users than were AIDS patients without tuberculosis. Fifty-one percent had tuberculosis diagnosed before AIDS, and 37 percent had AIDS diagnosed at least 1 month prior to the diagnosis of tuberculosis. Although the lungs were the most frequent site of tuberculosis in both AIDS and non-AIDS patients, 60% of the AIDS group had at least 1 extrapulmonary site of disease compared to 28% of the non-AIDS group (p less than 0.001). Nonsignificant tuberculin skin tests were more common in AIDS patients (14 of 23 patients tested) than in non-AIDS patients (12 of 129 patients tested; p less than 0.0001). Chest radiographs in AIDS patients showed predominantly diffuse or miliary infiltrates (60%), whereas non-AIDS patients had predominantly focal infiltrates and/or cavitation (68%). Response to antituberculosis therapy was favorable in AIDS patients, although adverse drug reactions occurred more frequently than in non-AIDS patients (p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Dental health of recent immigrant children in the Newcomer schools, San Francisco.

Dental screenings of 1,012 recent immigrant elementary school children in San Francisco showed 77 per cent of children needed dental treatment on first screening, compared to 25 per cent in the 1979-80 National Institute of Dental Research (NIDR) survey for the western United States. The prevalence of dental caries in primary teeth of the immigrant six and seven year-olds was twice that of their US counterparts. Non-refugee immigrants had more serious dental needs but used dental services less often than children with refugee status.

Phenotypic distribution of T cells of patients who have subsequently developed AIDS.

In a previous study of asymptomatic homosexual men, we found that CD8+ T-cell levels were higher in homosexual men infected with the human immunodeficiency virus (HIV) than in uninfected homosexual men because of higher numbers of CD8+ T cells that do not express the Leu15 marker, a phenotype associated with cytotoxic function. Among infected men, there was a positive correlation between the number of CD8+Leu15- T cells and the number of CD4+ T cells. If CD4+ T-cell levels are taken as a measure of severity of HIV infection and immunodeficiency, these results suggested that higher CD8+Leu15- cells may represent a phenotypic profile associated with less severe infection or better control of infection. In the present study, we extend the analysis to include a group of men who progressed to AIDS but were studied well before the onset of AIDS, and we compare results of CD8 subset analyses with results of infected men who have not progressed to AIDS. Phenotypic subsets associated with helper, suppressor, cytotoxic, and natural killer cell function were determined by two-color immunofluorescence. The only phenotypic subset that distinguished men who progressed to AIDS from those who have not was lower numbers of CD4+ T cells in the former group. If CD8+Leu15- cell numbers (or other phenotypic subsets examined) reflect effective control of HIV infection, the relationship is not strong enough to be of prognostic or predictive value with respect to outcome of infection.

Risk factors for human immunodeficiency virus (HIV) infections in homosexual men.

To clarify risk factors for infection with the human immunodeficiency virus (HIV) we selected at random 785 homosexual men who had participated in studies of hepatitis B in San Francisco in 1978-80 for a follow-up study of the acquired immunodeficiency syndrome. Although most had not been contacted in over five years, 492 (63 per cent) were located and enrolled. The 240 (67 per cent) who had developed antibodies to HIV, as measured by an enzyme-linked immunosorbent assay (ELISA), were compared with 119 who had remained seronegative. In multivariate analyses, receptive anal intercourse with ejaculation by nonsteady sexual partners, many sexual partners per month, and other indicators of high levels of sexual activity were highly associated with seroconversions. None of the sexual practices that we studied appeared to offer protection against HIV infection.

T-cytotoxic/suppressor cell phenotypes in a group of asymptomatic homosexual men with and without exposure to HTLV-III/LAV.

The number of lymphocytes bearing the Leu 2+ or T8+ (suppressor/cytotoxic) phenotype is elevated in asymptomatic homosexual men. By two-color immunofluorescence using paired monoclonal antibodies (alpha-Leu 2 and alpha-Leu 15, alpha-Leu 2 and alpha-Leu 7, alpha-Leu 7 and alpha-Leu 11), we enumerated phenotypic subpopulations that are associated with cytotoxic, suppressor, or natural killer function. Both cytotoxic (Leu 2+15-) and suppressor (bright Leu 2+15+) cell populations are elevated in homosexual men. Homosexual men who have been exposed to human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV) have higher numbers of Leu 2+15- and Leu 2+7- cells than homosexual men who have not been exposed. Phenotypic subpopulations (dim Leu 2+ Leu 15+ and Leu 7-11+) that are associated with the most potent natural killer activity (against K562 target cells) were not found to be elevated in homosexual men.

Long-term immunogenicity and efficacy of hepatitis B vaccine in homosexual men.

To study the duration of antibody persistence and protection provided by the hepatitis B vaccine, we followed 773 homosexual men for five years after completion of vaccination. Among the 635 participants in whom antibody levels above 9.9 sample ratio units (SRU) developed after vaccination, 15 percent lost antibody altogether, and in another 27 percent, antibody levels declined below 10 SRU within five years. The extent of the maximal antibody response strongly predicted the persistence of protective antibody. Hepatitis B infection occurred in 55 men; 8 of these infections were clinically important (characterized by the presence of the hepatitis B surface antigen and elevation of liver-enzyme levels), and two of the patients became hepatitis B virus carriers. The long-term risk of hepatitis B infection was inversely related to the maximal antibody response to vaccine. Most severe infections occurred among those who responded poorly or had no response to the vaccination. The risk of late infection with hepatitis B in those with an initially adequate vaccine response increased markedly when antibody levels decreased below 10 SRU, but only 1 of 34 late infections resulted in viremia and liver inflammation. A second series of vaccinations induced a moderate antibody response in 50 percent of the subjects who initially had no response or a poor response; however, the persistence of antibody was poor. Both antibody loss and the risk of severe disease should be considered when booster-dose strategies for the hepatitis B vaccine are being designed.

Identification of Mycobacterium tuberculosis antigens in Seibert fractions by immunoblotting.

Seibert fractions prepared from Mycobacterium tuberculosis culture filtrates were evaluated by immunoblotting with a serum pool from patients with active pulmonary tuberculosis. Antibody activity was observed primarily with antigens in the polysaccharide II and A protein fractions; these fractions were further evaluated by immunoblotting with sera from individual patients with tuberculosis, from individuals without tuberculosis and positive for the purified protein derivative antigen skin test, and from individuals negative for the purified protein derivative antigen skin test. The antigens identified in the protein A fraction, a 32,000-molecular-weight antigen and a heterogeneous high-molecular-weight antigen, reacted with antibody found in sera from all patients with tuberculosis and with antibody from over 25% of the control individuals. A 10,000-molecular-weight antigen, a 30,000- to 44,000-molecular-weight antigen, and a heterogeneous high-molecular-weight antigen were observed in the polysaccharide II fraction; these antigens reacted with serum antibody from 70% or more of the patients with tuberculosis and with antibody from 20 to 70% of the control individuals. One of the antigens, with a molecular weight ranging from 17,000 to 28,000 in the polysaccharide II fraction, reacted with antibody in 64% of the sera from patients with tuberculosis but with only 1 of 15 control normal sera. This antigen may elicit an antibody response specifically associated with tuberculosis.

The economic impact of the first 10,000 cases of acquired immunodeficiency syndrome in the United States.

Acquired immunodeficiency syndrome (AIDS) is a serious, fatal disease affecting a relatively young population and has a great economic impact. Expenditures for hospitalization and economic losses from disability and premature death were estimated for the first 10,000 patients with AIDS reported in the United States. Extrapolation of data from surveys done in New York City, Philadelphia, and San Francisco suggests that these 10,000 patients with AIDS will require an estimated 1.6 million days in the hospital, resulting in over $1.4 billion in expenditures. Losses incurred for the 8,387 years of work that will be lost from disability and from the premature death of the 10,000 patients will be over $4.8 billion. The total economic burden of the AIDS epidemic will continue to rise as the number of diagnosed cases increases. These estimates reinforce the need for effective disease prevention strategies to reduce the number of cases.

The acquired immunodeficiency syndrome in a cohort of homosexual men. A six-year follow-up study.

A cohort of 6875 homosexual men, initially seen at the San Francisco City Clinic between 1978 and 1980, were studied to determine the incidence and prevalence of the acquired immunodeficiency syndrome, related conditions, and infection with the human T-lymphotropic virus, type III/lymphadenopathy-associated virus (HTLV-III/LAV). By December 1984, 2.4% of the men had the syndrome; mortality attributable to the syndrome in 1984 was 600/100 000. For each man with the syndrome in a representative sample of 474 cohort members seen in 1984, 7.5 men had generalized lymphadenopathy, 1.1 had other prodromal findings, and 0.8 had hematologic abnormalities. Prevalence of serum antibodies to HTLV-III/LAV, measured by an enzyme-linked immunosorbent assay, increased from 4.5% in 1978 to 67.4% in 1984. Of 31 persons who were seropositive and without the syndrome between 1978 and 1980, 2 developed the syndrome and 8 developed related conditions during a median follow-up of 61 months. Over a 6-year period, two thirds of cohort members were infected with HTLV-III/LAV and almost one third developed related conditions.

Persistent infection with human T-lymphotropic virus type III/lymphadenopathy-associated virus in apparently healthy homosexual men.

PIP: A group of 14 apparently health homosexual men with serologic evidence of human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV) infection were studied to determine the duration of their seropositivity, their immunologic status, and the frequency of isolation of HTLV-III/LAV from their peripheral blood. The men were selected from a larger sample of patients who attended a clinic for treatment of sexually transmitted diseases in San Francisco because they did not have acquired immunodeficiency syndrome (AIDS), signs or symptoms suggestive of the prodrome of AIDS, or laboratory evidence of anemia or leukopenia. 4 or more serum samples were available from previous clinic visits. The men ranged in age from 26-41 years, and had a median number of sexual partners in the last year of 23. The estimated duration of seropositivity ranged from 4-69 months (median, 33 months). 11 of the 14 had T-helper: T-suppressor cell ratios below 1 (the lower limit of normal), and low ratios were significantly correlated with duration of seropositivity. HTLV-III/LAV was isolated in peripheral blood samples from 8 of 12 men tested. Culture-positive and culture-negative men did not differ significantly in terms of age, presence of a palpable lymph node, T helper:T-suppressor cell ratio, or duration of seropositivity. These findings suggest that some seropositive men may remain asymptomatic for at least 5 years. However, the isolation of HTLV-III/LAV from the peripheral blood of most of these men indicates persistent infection may be common among asymptomatic seropositive men at risk for AIDS. It should be assumed that these men have the potential to transmit HTLV-III/LAV infection.^ieng

Cultural variation--nutritional and clinical implications.

Cultural variation may play an important role in human nutrition and must be considered in either clinical or public health intervention particularly in areas with large immigrant populations. Acculturative and environmental change influence the food habits and health of transitional groups. Nutritional assessment may be complicated by cultural variation. The relationship between ethnicity and nutrition may be of evolutionary significance. Food beliefs may have beneficial or detrimental effects on health status. The study of acculturating populations may elucidate the pathogenesis of nutrition-related chronic diseases. Appreciation of the interaction of culture and nutrition may be of benefit to physicians and nutritionists in clinical practice and to those concerned with the prevention of nutrition-related chronic diseases.