Management of HIV infection. A 1995-96 overview for the clinician

Although the challenges of HIV/AIDS care may seem overwhelming, we are better able than ever to positively affect the course of HIV for each individual patient. Treatment goals involve three areas: 1) Antiretroviral drugs aimed at retarding the rate of HIV replication, thus reducing the rate of damage to the immune system; 2) drugs used to treat or prevent opportunistic infections seen in the context of HIV-related immune deficiency; and 3) drugs used to treat symptoms or syndromes commonly seen in these patients (including dementia and wasting syndrome). The multitude of clinical problems seen in advanced HIV disease leads to significant polypharmacy and costs resulting in a very complex and confusing situation. I recommend that physicians with little HIV experience link up with an HIV specialist when caring for HIV-infected patients to optimize access to the best therapies or research studies currently available. With no cure in sight, physicians need to focus on educating the public and patients about how to avoid HIV infection and to identify persons who are infected to minimize spread.

Peroxisome proliferator-activated receptor response specificities as defined in yeast and mammalian cell transcription assays

Peroxisome proliferators include a heterogeneous group of xenobiotic agents capable of inducing peroxisome proliferation and hepatocellular carcinomas in rodent model systems. These chemicals appear to mediate their activity through a family of transcription factors known as peroxisome proliferator-activated receptors (PPAR). Recently it has been shown that DNA binding of PPAR is contingent upon heterodimerization with a member of the retinoic acid X (RXR) family of receptors. In this report transcription parameters of a rat PPAR alpha were analyzed using mammalian and yeast cotransfection assays. PPAR activity was observed to be peroxisome proliferator dependent in the mammalian cotransfection assay, and heterodimer dependent but peroxisome proliferator independent in a yeast version of the same assay. Moreover, when the naturally occurring ligand for RXR, 9-cis-retinoic acid (RA), was tested in the same assays, it was observed to generate an RXR-specific response in the yeast cell assay but host cell-specific response in the mammalian cell assay. Finally, the combination of peroxisome proliferator and 9-cis-RA had very little added effect on the yeast cell assay but again produced a cell-specific synergistic response in the mammalian cell assay. These data demonstrate that PPAR transcriptional activity is strongly influenced by the RXR family of receptors, and that peroxisome proliferators may be regulating PPAR mammalian cell activity through a secondary mechanism.

Congenital cytomegalovirus infection as a result of nonprimary cytomegalovirus disease in a mother with acquired immunodeficiency syndrome

A pregnant woman with acquired immunodeficiency syndrome had nonprimary cytomegalovirus (CMV) viremia and died of complications from Pneumocystis carinii pneumonia and CMV sinusitis and pneumonitis. A boy was delivered by cesarean section at 34 weeks of gestation as the mother's health deteriorated and fetal distress developed. The infant died soon after delivery of interstitial pneumonitis and hyaline membrane disease with invasive CMV disease that affected the kidneys, adrenal glands, and placenta; the CMV strains from the mother and neonate were identical.

Nd:YAG laser treatment of retained Descemet's membrane after penetrating keratoplasty

Retention of the host's Descemet's membrane is an unusual complication of penetrating keratoplasty. The membrane may opacify and even threaten the health of the transplant. Following creation of a central opening with the Nd:YAG laser in such a case, visual acuity improved from counts fingers at 5 ft to 20/100.

Consumer participation in identifying research and development priorities for power wheelchair input devices and controllers

A focus group comprised of persons who use power wheelchairs and professionals working in the field were asked to participate in a brainstorming session to determine priorities for the development and application of power mobility input devices and control concepts. The group consensus was that durability and reliability are the most important criteria. Essentially, the expectation is that a power wheelchair must work everyday in the way a person needs it and wants it. At the same time, there is a desire to enhance and advance the features of input devices and control systems. Many would say these changes constitute designing "smarter" power wheelchairs, such as systems that can independently detect obstacles and can provide users with more feedback. This paper presents the rationale behind forming this focus group and details of the results of a brainstorming session where ideas were generated and prioritized. The five most important issues as determined by the group are discussed in depth.

Bilateral parotid MALT lymphoma and Sjögren's syndrome

A patient with Sjögren's syndrome who developed bilateral parotid lymphoma is described. The management is discussed emphasising difficult aspects of the diagnosis and treatment.

KP-1: not a specific marker. Staining of 137 sarcomas, 48 lymphomas, 28 carcinomas, 7 malignant melanomas and 8 cystosarcoma phyllodes

This study documents the reactions of the monoclonal antibody KP-1, which detects histiocytes in paraffin sections, with 137 sarcomas, 48 lymphomas, 28 carcinomas, 7 malignant melanomas and 8 cystosarcoma phyllodes. The soft tissue sarcomas had been previously immunophenotyped. Positive staining was obtained in all categories of sarcoma except clear-cell sarcomas. Most categories of sarcoma showed staining in less than 10% of tumour cells although a minority of leiomyosarcomas showed more extensive staining. Five of 7 malignant melanomas were also positive while all lymphomas and carcinomas were negative. We conclude that KP-1 positivity is not helpful in supporting the histiocytic origin of a tumour and is of limited value in the differential diagnosis of soft tissue sarcomas or their separation from other categories of malignancy.

Compliance with universal precautions and needle handling and disposal practices among emergency department staff at two community hospitals

BACKGROUND

To describe rates of needle disposal and barrier use within the emergency departments at two privately owned community hospitals in two suburbs of Minneapolis, a study was conducted. This study consisted of direct observation of a cohort of emergency department personnel providing patient care followed by a self-administered survey of the same personnel.

METHODS

From June through August 1990, seven specially trained registered nurses observed emergency department personnel for a total of 400 hours. The observers documented the appropriate rates of use of gowns, goggles, masks, and gloves. Observers also noted methods of needle disposal and frequency of needle recapping. After observation, surveys that included items requesting estimates of rates of use for each barrier, as well as estimates of the rates and methods of needle recapping and disposal, were distributed. For each observed and corresponding self-reported behavior, 95% confidence intervals were calculated and compared.

RESULTS

A total of 1,822 procedures were recorded. Gloves were observed to be used when appropriate 67.2% of the time, followed by goggles (50.7%), masks (16.0%), and gowns (15.3%). Self-reported barrier rates were slightly higher in all cases except for goggle use. About one third (34.4%) of the needles were recapped; 78.1% of these were recapped two-handed.

CONCLUSIONS

Previous studies have documented low universal precautions compliance rates at urban teaching hospitals. Our data indicate less than optimal levels of compliance also at community hospitals, and show that personnel are less than fully aware of their own noncompliance.

Variables influencing worker compliance with universal precautions in the emergency department

BACKGROUND

Emergency department health care workers frequently provide care to patients who are in unstable condition, bleeding, or in a crisis situation. To identify the variables described in the Health Belief Model affecting health care workers' compliance with practices and devices believed to reduce exposure to patients' blood, the staff of a level II trauma center were surveyed for knowledge, compliance, and training regarding universal precautions.

METHODS

Fifty-three health care workers responded to an anonymous, self-report, 50-item questionnaire. Significant differences in mean scores were determined by use of a two-tailed t test.

RESULTS

Health care workers estimated they were most likely to perform handwashing after contact with body fluids and to wear gloves if contact with blood was anticipated. The most common obstacles to compliance with universal precautions were lack of time, patients perceived to be at lower risk for HIV or hepatitis B infections, and interference with technical skills. Health care workers with more than three perceived obstacles to universal precautions were less likely to use gloves (p < 0.05) if contact with blood was anticipated. Health care workers with a higher number of training experiences in universal precautions were more likely to use gloves if contact with blood was anticipated (p < 0.05) and less likely to recap a needle after giving an intravascular injection (p < 0.05), drawing a blood gas sample (p < 0.05), or injecting medication into an intravenous line (p < 0.05).

CONCLUSIONS

The application of the Health Belief Model to this problem suggests that an integrated approach is appropriate. Such an approach should incorporate engineering controls, cognitive approaches, behavior modification strategies, and training experiences to improve skills and dexterity.

Clinical and histologic involvement of regional lymph nodes in malignant melanoma. Adjuvant vindesine improves survival

BACKGROUND

This report is a study of prognostic factors, including adjuvant chemotherapy, that influence survival of patients with malignant melanoma who have clinical and pathologic involvement of regional lymph nodes.

METHODS

A total of 169 evaluable patients with malignant melanoma metastatic to regional lymph nodes were registered consecutively and prospectively between June 1977 and December 1986 in the computerized data base of the melanoma registry at Westminster Hospital. Eighty-seven of these patients received adjuvant chemotherapy with vindesine after resection of palpable metastatic lymph nodes, and 82 had no systemic treatment after surgery. All were followed up for at least 2 years (median, 8 years) after involvement of regional lymph nodes was noted or until death. Statistical analyses included simple life-table comparisons, unadjusted for covariates. In addition, Breslow's thickness, ulceration of the primary lesion, its anatomical location, number of regional lymph nodes histologically involved, dissection site, patient age and sex, and adjuvant vindesine therapy were included as covariates in Cox regression models.

RESULTS

The disease-free interval (P = 0.0001), time to dissemination from lymph node metastases (P < 0.0001), survival time after lymph node dissection (P = 0.0227) and overall survival time after initial diagnosis of malignant melanoma (P = 0.0095, log-rank chi-square test) were superior for the 87 patients who received adjuvant chemotherapy with vindesine. Cox regression analysis confirmed adjuvant vindesine as a highly significant variable influencing all of these outcomes, including overall survival time after first diagnosis (P = 0.003).

CONCLUSIONS

The apparent effect of adjuvant vindesine on overall survival in this study is large (hazard ratio, 0.52) and highly statistically significant. Adjuvant vindesine therapy merits consideration for malignant melanoma metastatic to regional lymph nodes. However, these results observed in concurrent, but nonrandomized, patients clearly require confirmation.

The polarity of the induced electric field influences magnetic coil inhibition of human visual cortex: implications for the site of excitation

Human perception of 3 briefly flashed letters in a horizontal array that subtends a visual angle of 3 degrees or less is reduced by a magnetic coil (MC) pulse given, e.g., 90 msec later. Either a round or a double square MC is effective when the lower windings or central junction region, respectively, are tangential to the skull overlying calcarine cortex and symmetrical across the midline. The modeled, induced electric field has peak amplitude at the midline, but the peak spatial derivatives lie many centimeters laterally. Thus, the foveal representation near the midline is closer to the peak electric field than to its peak spatial derivatives, i.e., excitation of calcarine cortex differs from excitation of a straight nerve. With an MC pulse that induces an electric field which is substantially monophasic in amplitude, the lateral-most letter (usually the right-hand letter) in the trigram is preferentially suppressed when the electric field in the contralateral occipital lobe is directed towards the midline. Inferences from using peripheral nerve models imply that medially located bends in geniculo-calcarine or corticofugal fibers are the relevant sites of excitation in visual suppression; end excitation of fiber arborizations or apical dendrites is considered less likely. This conclusion is supported by the fact that the induced electric field polarity in paracentral lobule for optimally eliciting foot movements is opposite to that for visual suppression, the major bends occurring at different portions of the fiber trajectories in the two systems.

Current and future HIV/AIDS clinical research. HIV-related therapy improving--slowly

More than 300,000 cases of AIDS have been reported in the United States since 1981. Despite major scientific advances and much effort, the benefits of treatment have been modest. The variable nature of the human immunodeficiency virus (HIV) and the complexity of the immune system are the major obstacles to advances in treatment. This article summarizes the current state of clinical research in pursuit of improved HIV therapy and takes a look into the future of anti-HIV therapeutics. It also provides an overview of HIV clinical research underway in Minnesota. Research efforts to improve therapy of HIV-induced immune deficiency will involve three strategies: better anti-HIV drugs and combinations of drugs aimed at slowing the replication of HIV, immune-based therapies intended to stimulate the immune system, and multiple opportunistic pathogen prophylaxis strategies to prevent HIV-related opportunistic infections. This approach will involve considerable cost and polypharmacy. Improvements in HIV/AIDS therapy are likely to occur incrementally, but the endeavor needs widespread support from patients, physicians, and the public. For now, the best strategy is prevention, which is where physicians can have the greatest impact on the epidemic.

Deficits in AIDS/HIV knowledge among physicians and nurses at a Minnesota public teaching hospital

We administered a questionnaire pertaining to recent gains in knowledge about HIV/AIDS treatment and natural history in mid-1990 to all physicians and nurses at a 455-bed public teaching hospital. Surveys were returned by 127 physicians (46%) and 541 nurses (77%). Responses indicated that only 37% of physicians and 18% of nurses knew that the risk for an AIDS-related opportunistic infection becomes significant when the T-helper cell count falls below 200 cells per cubic millimeter. One-fourth of physicians (23%) and more than one-half of nurses (55%) were not aware that the HIV enzyme immunoassay test alone is insufficient to properly determine a patient's HIV serostatus. The survey results revealed a broad deficit in knowledge about the natural history and treatment of HIV infection and demonstrated the need for a clinically relevant core HIV/AIDS knowledge curriculum and for strategies to better educate health care providers to improve care given to HIV-infected patients.

A comparison of observed and self-reported compliance with universal precautions among emergency department personnel at a Minnesota public teaching hospital: implications for assessing infection control programs

STUDY OBJECTIVES

To determine the level of universal precautions compliance in a hospital emergency department by two methods (direct observation of subjects versus self-reporting by questionnaire).

SETTING

A Level II trauma center located within a university-affiliated medical center in Minneapolis/St Paul, Minnesota. Glove and needle disposal containers were available in each treatment room; gowns, masks, and goggles were readily available.

PARTICIPANTS

ED physicians (12 staff plus rotating residents), medical students, nursing staff, and ancillary personnel.

METHODS

Ten observers documented six specific behaviors among ED personnel: needle recap frequency, needle recap techniques, and use of gowns, gloves, masks, and goggles. After the observations, surveys were distributed to ED personnel by intrahospital mail in Fall 1989.

RESULTS

During 270 observation hours, 1,018 patient-worker interactions were recorded. Gloves were the barrier worn most frequently when appropriate (74%), followed by goggles (13%), gowns (12%), and masks (1%). Needles were recapped 51% of the time, and most needles that were recapped (79%) were recapped by the two-hand technique; 5% of all needles used were left uncapped at bedside or in the trash. Physicians were observed to use gloves more frequently than registered nurses and nursing assistants; nurses were observed to recap more frequently than physicians. From the survey, the three most common reasons for noncompliance involved time (71%), dexterity (61%), and patient appearance (50%).

CONCLUSION

Universal precautions are not consistently used by ED personnel, and ED personnel significantly overestimate their compliance with universal precautions.