Impact of hepatitis B on mortality and specific causes of death in adults with and without HIV co-infection in NYC, 2000-2011.

High rates of immigration from endemic countries contribute to the high chronic hepatitis B (HBV) prevalence in New York City (NYC) compared to the United States overall, i.e. about 1 million individuals. We describe the impact of HBV infection on mortality and specific causes of death in NYC. We matched surveillance and vital statistics mortality data collected from 2000 to 2011 by the New York City Department of Health and Mental Hygiene (DOHMH) and analysed demographics and premature deaths (i.e. whether death occurred at <65 years) in persons with and without chronic HBV or HIV infection (excluding those with hepatitis C). From 2000 to 2011, a total of 588 346 adults died in NYC. Of all decedents, 568 753 (97%) had no report of HIV or HBV, and 4346 (0·7%) had an HBV report. Of HBV-infected decedents, 1074 (25%) were HIV co-infected. Fifty-five percent of HBV mono-infected and 95% of HBV/HIV co-infected decedents died prematurely. HBV disproportionately impacts two subgroups: Chinese immigrants and HIV-infected individuals. These two subgroups are geographically clustered in different neighbourhoods of NYC. Tailoring prevention and treatment messages to each group is necessary to reduce the overall burden of HBV in NYC.

HIV and viral hepatitis co-infection in New York City, 2000-2010: prevalence and case characteristics.

Using surveillance data, we describe the prevalence and characteristics of individuals in New York City (NYC) co-infected with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) and/or hepatitis C virus (HCV). Surveillance databases including persons reported to the NYC Department of Health and Mental Hygiene with HIV, HBV, and HCV by 31 December 2010 and not known to be dead as of 1 January 2000, were matched with 2000-2011 vital statistics mortality data. Of 140 606 persons reported with HIV, 4% were co-infected with HBV only, 15% were co-infected with HCV only, and 1% were co-infected with HBV and HCV. In all groups, 70-80% were male. The most common race/ethnicity and HIV transmission risk groups were non-Hispanic blacks and men who have sex with men (MSM) for HIV/HBV infection, and non-Hispanic blacks, Hispanics, and injection drug users for HIV/HCV and HIV/HBV/HCV infections. The overall age-adjusted 2000-2011 mortality was higher in co-infected than HIV mono-infected individuals. Use of population-based surveillance data provided a comprehensive characterization of HIV co-infection with HBV and HCV. Our findings emphasize the importance of targeting HIV and viral hepatitis testing and prevention efforts to populations at risk for co-infection, and of integrating HIV and viral hepatitis care and testing services.

Characteristics and TB treatment outcomes in TB patients with viral hepatitis, New York City, 2000-2010.

Literature surrounding the burden of and factors associated with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in persons with tuberculosis (TB) disease remains limited and focused on populations outside the USA. Cross-matched New York City (NYC) TB and viral hepatitis surveillance data were used to estimate the proportion of NYC adults diagnosed with TB from 2000 to 2010 with a report of viral hepatitis infection and to describe the impact of viral hepatitis infection on TB treatment completion and death. For 9512 TB patients, HCV infection was reported in 4.2% and HBV infection in 3.7%; <1% of TB patients had both HCV and HBV infection. The proportion of TB patients with HCV infection to die before TB treatment completion was larger than in TB patients without a viral hepatitis report (21% vs. 9%); this association remained when stratified by HIV status. There was no significant difference in death before treatment completion for TB patients with HBV infection compared to TB patients without a viral hepatitis report when stratified by HIV status. These findings reinforce the importance of hepatitis testing and providing additional support to TB patients with viral hepatitis infection.

Do Not Attempt Cardiopulmonary Resuscitation orders in acute medical settings: a qualitative study.

BACKGROUND: Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders have been shown to be independently associated with patients receiving fewer treatments, reduced admission to intensive care and worse outcomes even after accounting for known confounders. The mechanisms by which they influence practice have not previously been studied. OBJECTIVES: To present a rich qualitative description of the use of the DNACPR form in a hospital ward setting and explore what influence it has on the everyday care of patients. DESIGN: Multi-source qualitative study, primarily using direct observation and semi-structured interviews based on two acute wards in a typical middle-sized National Health Service hospital in UK. RESULTS: The study identified a range of ways in which DNACPR orders influence ward practice, beyond dictating whether or not cardiopulmonary resuscitation should be attempted. Five key themes encapsulate the range of potential impacts emerging from the data: the specific design and primacy of the form, matters relating to clinical decision making, staff reflections on how the form can affect care, staff concern over 'inappropriate' resuscitation, and discussions with patients/relatives about DNACPR decisions. Overall, it was found that while the DNACPR form is recognized as serving a useful purpose, its influence negatively permeated many aspects of clinical practice. CONCLUSION: DNACPR orders can act as unofficial 'stop' signs and can often signify the inappropriate end to clinical decision making and proactive care. Many clinicians were uncomfortable discussing DNACPR orders with patients and families. These findings help understand why patients with DNACPR orders have worse outcomes, as such they may inform improvements in resuscitation policies.

Creatine supplementation during pulmonary rehabilitation in chronic obstructive pulmonary disease.

BACKGROUND: Skeletal muscle wasting and dysfunction are strong independent predictors of mortality in patients with chronic obstructive pulmonary disease (COPD). Creatine nutritional supplementation produces increased muscle mass and exercise performance in health. A controlled study was performed to look for similar effects in 38 patients with COPD. METHODS: Thirty eight patients with COPD (mean (SD) forced expiratory volume in 1 second (FEV(1)) 46 (15)% predicted) were randomised to receive placebo (glucose polymer 40.7 g) or creatine (creatine monohydrate 5.7 g, glucose 35 g) supplements in a double blind trial. After 2 weeks loading (one dose three times daily), patients participated in an outpatient pulmonary rehabilitation programme combined with maintenance (once daily) supplementation. Pulmonary function, body composition, and exercise performance (peripheral muscle strength and endurance, shuttle walking, cycle ergometry) took place at baseline (n = 38), post loading (n = 36), and post rehabilitation (n = 25). RESULTS: No difference was found in whole body exercise performance between the groups: for example, incremental shuttle walk distance mean -23.1 m (95% CI -71.7 to 25.5) post loading and -21.5 m (95% CI -90.6 to 47.7) post rehabilitation. Creatine increased fat-free mass by 1.09 kg (95% CI 0.43 to 1.74) post loading and 1.62 kg (95% CI 0.47 to 2.77) post rehabilitation. Peripheral muscle performance improved: knee extensor strength 4.2 N.m (95% CI 1.4 to 7.1) and endurance 411.1 J (95% CI 129.9 to 692.4) post loading, knee extensor strength 7.3 N.m (95% CI 0.69 to 13.92) and endurance 854.3 J (95% CI 131.3 to 1577.4) post rehabilitation. Creatine improved health status between baseline and post rehabilitation (St George's Respiratory Questionnaire total score -7.7 (95% CI -14.9 to -0.5)). CONCLUSIONS: Creatine supplementation led to increases in fat-free mass, peripheral muscle strength and endurance, health status, but not exercise capacity. Creatine may constitute a new ergogenic treatment in COPD.

Performance enhancement in chronic obstructive pulmonary disease.

BACKGROUND: Exercise limitation is a hallmark of chronic obstructive pulmonary disease (COPD) and is integral to the associated impaired health status of these patients. The poor exercise tolerance is multifactorial in origin, relating to airflow obstruction, disadvantageous lung mechanics, reduced oxygen delivery and skeletal muscle dysfunction. A number of interventions have been studied to determine whether they can impact on exercise performance. The most evidence-based of these is exercise training, which along with other approaches, both previously investigated and putative, are discussed in this review.

The pattern and timing of breathing during incremental exercise: a normative study.

Clinical evaluation of the pattern and timing of breathing during submaximal exercise can be valuable for the identification of the mechanical ventilatory consequences of different disease processes and for assessing the efficacy of certain interventions. Sedentary individuals (60 male/60 female, aged 20-80 yrs) were randomly selected from >8,000 subjects and submitted to ramp incremental cycle ergometry. Tidal volume (VT)/resting inspiratory capacity, respiratory frequency, total respiratory time (Ttot), inspiratory time (TI), expiratory time (TE), duty cycle (TI/Ttot) and mean inspiratory flow (VT/TI) were analysed at selected submaximal ventilatory intensities. Senescence and female sex were associated with a more tachypnoeic breathing pattern during isoventilation. The decline in Ttot was proportional to the TI and TE reductions, i.e. TI/Ttot was remarkably constant across age strata, independent of sex. The pattern, but not timing, of breathing was also influenced by weight and height; a set of demographically and anthropometrically based prediction equations are therefore presented. These data provide a frame of reference for assessing the normality of some clinically useful indices of the pattern and timing of breathing during incremental cycle ergometry in sedentary males and females aged 20-80 yrs.

Consistent condom use among drug-using youth in a high HIV-risk neighbourhood.

The objectives of this study were to determine predictors of consistent condom use in heterosexual relationships of young adults who use hard drugs in a neighbourhood with widespread drug-use-connected HIV. We interviewed 196 18-24 year olds who injected drugs or used heroin, cocaine or crack in the prior year and lived in the Bushwick neighbourhood of New York City. Interviews covered sociodemographics, substance use and sexual networks. The unit of analysis is the relationship; the dependent variable measures consistent condom use over the prior 30 days in a given relationship. Consistent condom use was reported in 26% of 377 non-commercial relationships and in all of 22 commercial relationships. Using multiple logistic regression, consistent condom use in non-commercial relationships was more likely in relationships that are not 'very close'; for men (but not women) with peers whose norms are more favourable to condom use; and for subjects who had concurrent sex partners in the last 12 months. In conclusion, we found that: (1) the lack of relationship between the peer norms of drug-using women and their condom use suggests they may have little control over condom use in their relationships-programmes should attempt to empower young women drug users and to develop ways for their peers to influence the men in their lives; (2) epidemiologically, the positive association of concurrency to consistent condom use suggests that condom use may be restricting HIV spread through the community-the presence of consistent condom use in all of the commercial sexual relationships also may restrict HIV spread; (3) prevention efforts should attempt to change peer cultures as a way to develop self-sustaining risk reduction. These changes should include changes in gender roles and power relations.

Hospital at home services for acute exacerbation of chronic obstructive pulmonary disease: a survey of British practice.

OBJECTIVES: To identify the prevalence of and attitudes towards hospital at home services for acute exacerbation of chronic obstructive pulmonary disease (COPD) in Great Britain. To identify the models of service in existence, in particular staff numbers and the workload experienced. DESIGN: A postal survey was used to locate existing schemes. Telephone interviews were conducted with each of the hospital at home services identified. SUBJECTS & SETTING: A questionnaire was sent to one consultant in each of 223 respiratory departments in Great Britain. Thirty six departments were subsequently contacted by telephone. OUTCOME MEASURES: Awareness and prevalence of hospital at home services. Perceived problems with starting a service. Details of organisation of existing services. RESULTS: We received 186 replies to the postal questionnaire. Of these respiratory departments, 179 (96%) were aware of hospital at home services for acute exacerbation of COPD and, in November 1999, 30 (16%) were running such a service. Difficulty in obtaining funding was the main reason for not setting up a service rather than lack of evidence of benefit or unsuitability of local circumstances. Median staffing level was two nurses (range one to six) looking after a median number of new patients of five per week (range 0.5 to 12). There was wide variation in the organisation of services. CONCLUSIONS: Despite lack of objective evidence of effectiveness, there was a high level of awareness of and interest in starting hospital at home services for acute exacerbation of COPD in British respiratory departments when assessed in November 1999.