Informing online professional dietetics practice: The development and pilot testing of the Social Media Evaluation Checklist

AIM

To develop and pilot a tool to evaluate Australian dietitians' and student dietitians' ethical and professional practice using social media.

METHODS

A Social Media Evaluation Checklist was developed based on checklist development literature with a four-staged process. Stage one included a literature review and input from an expert panel to ensure content validity. Stages two and three were to ensure face validity by categorising the checklist and pilot testing the tool. Instagram profiles and posts were audited by two authors using the checklist in the final stage to analyse ethical and professional use. An account purposely created for this study was used, and the first 25 dietitian and first 25 student dietitian profiles identified using the key words 'dietitian', 'student dietitian' and 'dietitian student' and the hashtag '#australiandietitian' were reviewed.

RESULTS

A total of 50 Instagram profiles and 250 posts were audited based on seven categories; (1) financial disclosure, (2) cultural awareness, (3) evidence-based information, (4) transparency, (5) privacy/confidentiality, (6) professionalism and (7) justifiability. Areas for improvement included advertising transparency which was met in only 12% of dietitian posts, and the provision of evidence-based information, which was met in 56% of dietitian posts and 72% of student dietitian posts.

CONCLUSIONS

This study provides insight into the ethical and professional use of social media by Australian dietitians and dietetics students. With the evolving nature of social media, guidance is required. This will ensure dietitians remain, now and in the future, the credible source of nutrition information for the public.

Mapping Simulated-Based Learning Experiences Incorporated Into Professional Placements in Allied Health Programs: A Scoping Review

SUMMARY STATEMENT

Emerging literature continues to demonstrate the use of innovative practices such as simulated-based learning experiences to prepare students for professional placements. This scoping review aimed to provide a broad overview of how simulated-based learning experiences have been implemented within or immediately before the professional practice placements of entry-level allied health programs. Four databases (MEDLINE, EMCARE, CINAHL, and Scopus) were searched up to August 2020. Kirkpatrick's evaluation framework was used to categorize outcomes, and the Simulation-Based Research Extension for the CONSORT statement was used to appraise the quality of simulation reporting. The search revealed 6584 unique abstracts with 321 full-text articles reviewed. Forty-eight studies met the inclusion criteria. This review has shown a clear trend toward using simulation within or immediately before the professional practice placements of allied health programs. Using Kirkpatrick's evaluation framework, most studies reported on student reaction (level 1) and learning (level 2) obtained during the simulation experience. There was limited evidence showing how the benefits gained in simulation translated to the clinical environment (level 3) or impacted the organization (level 4). Further research is required to review the optimal proximity of simulation to allied health professional placements and how gains are obtained from simulation transition to the clinical environment. In addition, more consistent reporting of simulation methodologies and evaluation methods are needed to strengthen the evidence base.

Starting from scratch: Developing and sustaining a rural research team lessons from a nutrition and dietetics case study

OBJECTIVE

To describe the development of and key factors for sustaining a rural-based research team focussed on nutrition and dietetics.

DESIGN

A longitudinal embedded case study approach with data sourced from publicly available records and observations. Case study sub-units were developed into 3 phases with analysis using theoretical propositions and pattern matching. Quantitative data were descriptively analysed.

SETTING

University of Newcastle Department of Rural Health across 4 rural sites.

PARTICIPANTS

Publicly available data sources from existing team members.

MAIN OUTCOME MEASURES

Staffing levels, research supervision, internal and external grant outcomes and peer-reviewed journal publications.

RESULT

Academic staffing has increased by 4 full-time equivalent positions over 18 years, with 6 current higher-degree research students. Key factors identified in the development of a discipline-specific research workforce included staff higher degree by research completions, longevity of staff in research-active roles, immersive rural placements with a research component and collaborations with nationally competitive researchers. Rural pilot research projects, community connections, understanding of the local context and research networks were fundamental to establishing a viable team.

CONCLUSION

Systematically investing in research that is embedded in local communities will ensure sustainability and relevance, capacity building of existing staff and an ability to problem solve at the local level. Sustained and focussed investment is needed if the current rural research workforce is to develop towards a capacity that meets current demand.

Estimation of spatiotemporal trends in bat abundance from mortality data collected at wind turbines

Renewable energy sources, such as wind energy, are essential tools for reducing the causes of climate change, but wind turbines can pose a collision risk for bats. To date, the population-level effects of wind-related mortality have been estimated for only 1 bat species. To estimate temporal trends in bat abundance, we considered wind turbines as opportunistic sampling tools for flying bats (analogous to fishing nets), where catch per unit effort (carcass abundance per monitored turbine) is a proxy for aerial abundance of bats, after accounting for seasonal variation in activity. We used a large, standardized data set of records of bat carcasses from 594 turbines in southern Ontario, Canada, and corrected these data to account for surveyor efficiency and scavenger removal. We used Bayesian hierarchical models to estimate temporal trends in aerial abundance of bats and to explore the effect of spatial factors, including landscape features associated with bat habitat (e.g., wetlands, croplands, and forested lands), on the number of mortalities for each species. The models showed a rapid decline in the abundance of 4 species in our study area; declines in capture of carcasses over 7 years ranged from 65% (big brown bat [Eptesicus fuscus]) to 91% (silver-haired bat [Lasionycteris noctivagans]). Estimated declines were independent of the effects of mitigation (increasing wind speed at which turbines begin to generate electricity from 3.5 to 5.5 m/s), which significantly reduced but did not eliminate bat mortality. Late-summer mortality of hoary (Lasiurus cinereus), eastern red (Lasiurus borealis), and silver-haired bats was predicted by woodlot cover, and mortality of big brown bats decreased with increasing elevation. These landscape predictors of bat mortality can inform the siting of future wind energy operations. Our most important result is the apparent decline in abundance of four common species of bat in the airspace, which requires further investigation.

The Safety of Discontinuation of Maintenance Therapy for Cytomegalovirus (CMV) Retinitis and Incidence of Immune Recovery Uveitis Following Potent Antiretroviral Therapy

BACKGROUND

Reconstitution of immune function during potent antiretroviral therapy can prompt discontinuation of maintenance cytomegalovirus (CMV) therapy but has also been associated with sight-threatening inflammatory conditions including immune recovery uveitis (IRU).

METHOD

Patients with inactive CMV retinitis and a CD4+ cell count above 100/mm3, receiving CMV therapy and stable combination antiretroviral therapy, were assigned to one of two groups based on willingness to discontinue CMV therapy.

RESULTS

Thirty-eight participants were enrolled: 28 discontinued anti-CMV therapy (Group 1) and 10 continued CMV treatment (Group 2). Median on-study follow-up was 16 months. One Group 1 participant who experienced an increase in plasma HIV viral load and a decline in CD4+ cell count developed confirmed progression of CMV retinitis. Progression or reactivation CMV retinitis was not observed among Group 2. IRU was present at study entry in 3 participants. Six participants in Group 1 and 3 participants in Group 2 developed IRU on-study. CMV viremia was not detected in any participants, and urinary shedding of CMV was intermittent.

CONCLUSION

Recurrence of CMV retinitis following discontinuation of anti-CMV therapy among patients with antiretroviral-induced increases in CD4+ cell count was rare. However, IRU was common in both those who maintained and discontinued anti-CMV therapy.

An innovative dietetic student placement model in rural new South wales, australia

Over the past 10 years, the University of Newcastle Department of Rural Health, based in Tamworth, New South Wales, has supported increased opportunities for short- and long-term rural dietetic placements through an ongoing collaboration between Hunter New England Local Health District dietitians and University of Newcastle academic staff, using an innovative student placement model. A recent strategy has been the implementation of year-long student attachments to a rural area in an attempt to improve long-term recruitment and retention of staff to rural and remote areas. This paper describes the dietetic student placement model and outcomes to date. There has been an increase in the number and diversity of student placements in Tamworth, from 2 student placements in 2002 to 33 in 2013 and a maximum increase of 317 student weeks. Students have rated the short- and long-term options highly. Intention to work rurally after graduation was reported at 49% for the 2011/2012 cohort of students. Seventy-three percent of all year-long students have obtained work in a rural setting after graduation. An increased exposure to a rural location has the potential to increase the recruitment of staff in rural areas.

Meta-analysis of the safety, tolerability, and efficacy of lopinavir/ritonavir-containing antiretroviral therapy in HIV-1-infected women

PURPOSE

Women comprise ≯50% of HIV-infected patients, yet safety, tolerability, and efficacy data in women taking antiretrovirals (ARVs) are limited. Lopinavir/ ritonavir (LPV/r)-anchored regimens are globally the most widely prescribed HIV-1 protease inhibitor regimens. The objective was to investigate the safety and efficacy of LPV/r-based therapy in women.

METHODS

A database query yielded all available data in HIV-1-infected subjects receiving LPV/r-based triple-ARV regimens from randomized clinical trials lasting ≥48 weeks from Abbott or Abbott-supported AIDS Clinical Trials Group studies. Efficacy (HIV-1 RNA levels, CD4+ T-cell counts) and safety and tolerability (treatment discontinuation, treatment-related adverse events [AE], and clinical laboratory abnormalities) at 48 weeks were assessed for total women, women by age (≥50, <50 years) and body mass index (BMI; <25, ≥25 to <30, ≥30 kg/m2), and sex.

RESULTS

Nine hundred ninety-two women initiated LPV/r-based therapy (of whom 79.2% were ARV-naïve), with 83.6% completing 48 weeks of treatment. There were 75.5% of women who achieved a threshold of HIV RNA <400 copies/mL by intent-to-treat, non-completer equals failure (ITT, NC = F) analysis, with a mean ± SE CD4+ T-cell count increase of 191.6 ± 4.92 cells/mm3 from baseline. Women aged ≥50 versus <50 years had higher incidence of moderate-to-severe treatment-related AEs and certain laboratory abnormalities, better virologic response (HIV RNA <400 copies/mL by ITT, NC = F), similar immunologic responses, and similar overall incidence of treatment discontinuations. Higher incidences of certain moderate-to-severe treatment-related AEs and laboratory abnormalities occurred in women with BMI ≥30 kg/m2; however, no effect of BMI on efficacy or discontinuation was observed.

CONCLUSIONS

LPV/r-based regimens were efficacious and well-tolerated in women without marked differences based on age and BMI categories evaluated.

The acceptability of a directly-administered antiretroviral therapy (DAART) intervention among patients in public HIV clinics in Los Angeles, California

Directly administered antiretroviral therapy (DAART) is an intensive adherence support strategy for highly active antiretroviral therapy (HAART) that requires patient acceptance to be effective. In one arm of a randomized adherence study, community workers (CW) delivered and observed ingestion of one HAART dose to participants five days a week for six months. We evaluated acceptability by study participation, retention, attendance and a satisfaction survey. Chi-square and nonparametric tests were used to examine differences between participants who did and did not complete DAART. Between November 2001 and March 2004, 416 eligible participants were identified; 250 were enrolled and 166 refused to participate (22 of these (13%) because of DAART specifically). Of the 82 randomized to DAART (70% Latino, 20% African American, 27% female and 69% foreign-born), 65 (79%) completed six months of DAART. Participants attended 6,953/7,390 (94%) appointments. Latinos were more likely to complete DAART compared to African Americans (OR=4.76, 95%CI=1.38, 16.44, p=0.01). In addition, foreign-born participants were more likely to complete DAART than US-born participants (OR=3.38, 95%CI=1.11-10.22, p=0.03). Participants completing DAART reported high rates of satisfaction. Retention, attendance and participant satisfaction suggest that DAART is an acceptable adherence support strategy in this public clinic population, particularly among Latino and foreign-born participants.

Comparison of first-line antiretroviral therapy with regimens including nevirapine, efavirenz, or both drugs, plus stavudine and lamivudine: a randomised open-label trial, the 2NN Study

BACKGROUND

The 2NN Study was a randomised comparison of the non-nucleoside reverse-transcriptase inhibitors (NNRTI) nevirapine and efavirenz.

METHODS

In this multicentre, open-label, randomised trial, 1216 antiretroviral-therapy-naive patients were assigned nevirapine 400 mg once daily, nevirapine 200 mg twice daily, efavirenz 600 mg once daily, or nevirapine (400 mg) and efavirenz (800 mg) once daily, plus stavudine and lamivudine, for 48 weeks. The primary endpoint was the proportion of patients with treatment failure (less than 1 log(10) decline in plasma HIV-1 RNA in the first 12 weeks or two consecutive measurements of more than 50 copies per mL from week 24 onwards, disease progression [new Centers for Disease Control and Prevention grade C event or death], or change of allocated treatment). Analyses were by intention to treat.

FINDINGS

Treatment failure occurred in 96 (43.6%) of 220 patients assigned nevirapine once daily, 169 (43.7%) of 387 assigned nevirapine twice daily, 151 (37.8%) of 400 assigned efavirenz, and 111 (53.1%) of 209 assigned nevirapine plus efavirenz. The difference between nevirapine twice daily and efavirenz was 5.9% (95% CI -0.9 to 12.8). There were no significant differences among the study groups in the proportions with plasma HIV-1 RNA concentrations below 50 copies per mL at week 48 (p=0.193) or the increases in CD4-positive cells (p=0.800). Nevirapine plus efavirenz was associated with the highest frequency of clinical adverse events, and nevirapine once daily with significantly more hepatobiliary laboratory toxicities than efavirenz. Of 25 observed deaths, two were attributed to nevirapine.

INTERPRETATION

Antiretroviral therapy with nevirapine or efavirenz showed similar efficacy, so triple-drug regimens with either NNRTI are valid for first-line treatment. There are, however, differences in safety profiles. Combination of nevirapine and efavirenz did not improve efficacy but caused more adverse events.

Ictal magnetic source imaging as a localizing tool in partial epilepsy

OBJECTIVE

To determine the feasibility and usefulness of ictal magnetoencephalography (MEG) recordings in the presurgical evaluation of patients with epilepsy.

METHODS

Twenty patients with frequent or predictable seizures were studied with the intent to capture seizures using a large array single-probe 37-channel or dual-probe 74-channel biomagnetometer.

RESULTS

Successful ictal MEG recordings were made in 6 of 20 patients with neocortical epilepsy. In one other patient, a seizure was captured but movement artifact made MEG recordings impossible. As determined by invasive EEG recording and postsurgical outcome, ictal MEG provided localizing information that was superior to interictal MEG in three of the six patients. Localization of ictal onset by MEG was at least equivalent to invasive EEG in five of the six patients, and was superior in two patients as determined by postsurgical outcome.

CONCLUSION

Larger studies are necessary to confirm that ictal MEG recordings in patients with frequent or easily provoked neocortical seizures can contribute localizing information equivalent or superior to invasive EEG recording.

Frequency of anovulation and early menopause among women enrolled in selected adult AIDS clinical trials group studies

To obtain information on the prevalence of anovulation and early menopause and on pituitary-gonadal function among human immunodeficiency virus type 1-infected women, a study was undertaken that used stored serum samples from women aged 20-42 years who participated in selected Adult AIDS Clinical Trials Group protocols. Defined progesterone and follicle-stimulating hormone (FSH) levels were considered presumptive evidence of ovulation and of menopause, respectively. Anovulation occurred in 16 (48%) of 33 women for whom progesterone levels were tested; early menopause occurred in 2 (8%) of 24 women for whom FSH levels were tested. No statistically significant differences were seen in the demographic and clinical characteristics of anovulatory and ovulatory women, although women who ovulated had higher CD4 T cell counts and were less likely to have reported a recent change in menstrual periods. These data support the findings of prior studies of increased frequency of amenorrhea and/or irregular menstrual cycles, particularly among women with lower CD4 T cell counts.

Patterns of plasma human immunodeficiency virus type 1 RNA response to antiretroviral therapy

Early identification of treatment failure among human immunodeficiency virus (HIV) type 1--infected patients receiving antiretroviral therapy could enable clinicians to modify inadequate regimens and to improve treatment response. Clinical definitions of treatment failure, however, may not be ideally suited for this purpose. This study empirically characterizes the patterns of HIV-1 RNA response to antiretroviral therapy in patients in 4 AIDS clinical trials. The approach assumed 2 patterns of HIV-1 response: "on track," for eventual suppression to HIV-1 RNA levels below the limit of quantification, and "off track," for deviation from this response. The results of this on- or off-track classification generally agreed with the protocol-defined outcomes of virologic success and failure, thus validating these commonly used definitions. Overall, only a minority of patients went off track because of suboptimal HIV-1 RNA response by the first follow-up visit. Most patients who went off track did so at later time points and had sharp unexpected rebounds without prior indication of a suboptimal response.

A randomized, controlled trial of indinavir, zidovudine, and lamivudine in adults with advanced human immunodeficiency virus type 1 infection and prior antiretroviral therapy

A randomized, double-blind, multicenter study of indinavir, zidovudine, and lamivudine was conducted in 320 adults with human immunodeficiency virus type 1 (HIV-1) infection, </=50 CD4 cells/mm3, and extensive prior zidovudine therapy. Patients received indinavir, 800 mg every 8 h; zidovudine, 200 mg every 8 h, and lamivudine, 150 mg twice daily; or all 3 drugs for 24 weeks. In an intention-to-treat analysis, proportions of patients with HIV-1 RNA <500 and <50 copies/mL, respectively, at week 24 were 56% and 45% in the indinavir-zidovudine-lamivudine group, 3% and 2% in the indinavir group, and 0% in the zidovudine-lamivudine group. Observed mean CD4 cell increases were 95, 78, and 6 cells/mm3 in the three-, one-, and two-drug arms, respectively. Regimens were generally well tolerated. Patients with advanced HIV-1 infection benefit from triple therapy with indinavir, zidovudine, and lamivudine, although the proportion with optimal response appeared to be lower in patients with low CD4 cell counts.

Constant mean viral copy number per infected cell in tissues regardless of high, low, or undetectable plasma HIV RNA

Quantitative analysis of the relationship between virus expression and disease outcome has been critical for understanding HIV-1 pathogenesis. Yet the amount of viral RNA contained within an HIV-expressing cell and the relationship between the number of virus-producing cells and plasma virus load has not been established or reflected in models of viral dynamics. We report here a novel strategy for the coordinated analysis of virus expression in lymph node specimens. The results obtained for patients with a broad range of plasma viral loads before and after antiretroviral therapy reveal a constant mean viral (v)RNA copy number (3.6 log10 copies) per infected cell, regardless of plasma virus load or treatment status. In addition, there was a significant but nonlinear direct correlation between the frequency of vRNA+ lymph node cells and plasma vRNA. As predicted from this relationship, residual cells expressing this same mean copy number are detectable (frequency <2/10(6) cells) in tissues of treated patients who have plasma vRNA levels below the current detectable threshold (<50 copies/ml). These data suggest that fully replication-active cells are responsible for sustaining viremia after initiation of potent antiretroviral therapy and that plasma virus titers correlate, albeit in a nonlinear fashion, with the number of virus-expressing cells in lymphoid tissue.

Initial increase in blood CD4(+) lymphocytes after HIV antiretroviral therapy reflects redistribution from lymphoid tissues

Previous studies proposed a dynamic, steady-state relationship between HIV-mediated cell killing and T-cell proliferation, whereby highly active antiretroviral therapy (HAART) blocks viral replication and tips the balance toward CD4(+) cell repopulation. In this report, we have analyzed blood and lymph node tissues obtained concurrently from HIV-infected patients before and after initiation of HAART. Activated T cells were significantly more frequent in lymph node tissue compared with blood at both time points. Ten weeks after HAART, the absolute number of lymphocytes per excised lymph node decreased, whereas the number of lymphocytes in the blood tended to increase. The relative proportions of lymphoid subsets were not significantly changed in tissue or blood by HAART. The expression levels of mRNA for several proinflammatory cytokines (IFN-gamma, IL-1beta, IL-6, and macrophage inflammatory protein-1alpha) were lower after HAART. After therapy, the expression of VCAM-1 and ICAM-1 -- adhesion molecules known to mediate lymphocyte sequestration in lymphoid tissue -- was also dramatically reduced. These data provide evidence suggesting that initial increases in blood CD4(+) cell counts on HAART are due to redistribution and that this redistribution is mediated by resolution of the immune activation that had sequestered T cells within lymphoid tissues.

Pharmacokinetics of saquinavir, zidovudine, and zalcitabine in combination therapy

We investigated the pharmacokinetics of zidovudine, zalcitabine, and saquinavir in AIDS Clinical Trial Group protocol 229. Patients received either saquinavir, zalcitabine, or a combination of both, together with zidovudine three times a day. Approximately 100 patients were enrolled in each treatment arm, and intensive pharmacokinetic studies were performed on about 25 patients per arm at weeks 1 and 12. We estimated the pharmacokinetic parameters of all three drugs by using parametric and nonparametric methods. The mean values of the pharmacokinetic parameters of zidovudine (clearance [CL]/bioavailability [F], 168 liters/h; volume of distribution [V]/F, 185 liters; half-life, 0.76 h) and zalcitabine (CL/F, 25 liters/h; V/F, 92.2 liters; half-life, 2.7 h) were similar to those reported previously. For saquinavir, the mean pharmacokinetic parameter estimates using parametric methods were as follows: maximum concentration of drug in serum [Cmax], 70.8 ng/ml; time to Cmax, 3.11 h; area under the curve, 809 ng x h/ml; CL/F, 989 liters/h; V/F, 1,503 liters; half-life, 1.38 h. For all three drugs, clearance decreased with age. Weight did not influence the clearance of zidovudine, but the clearance of zalcitabine and saquinavir increased with weight. There were no differences in pharmacokinetic parameters between study weeks and arms, suggesting that there is no change in kinetics with chronic administration and that there are no significant pharmacokinetic interactions among these three drugs.

Itraconazole maintenance treatment for histoplasmosis in AIDS: a prospective, multicenter trial

PURPOSE

To study the efficacy and safety of maintenance treatment with itraconazole for disseminated histoplasmosis in patients with AIDS.

PATIENTS AND METHODS

This was a prospective, multicenter, open-label study conducted at university-based hospitals participating in the AIDS Clinical Trial Group (ACTG). Forty-six AIDS patients with mild to moderate disseminated histoplasmosis who had successfully completed 12 weeks of induction treatment with itraconazole were treated with itraconazole, 200 mg once daily (42 patients) or 400 mg once daily (4 patients). Patients were followed at monthly intervals with clinical and laboratory assessment for relapse or toxicity. Primary outcome measures were relapse of histoplasmosis and survival. Secondary outcome measures included drug-limiting toxicity and changes in serum and urine Histoplasma polysaccharide antigen (HPA) levels.

RESULTS

Two patients relapsed during a median follow-up period of 87 weeks. The 1-year relapse-free rate was estimated to be 95.3% (95% CI, 85.3%-99.7%). One relapse may have been related to poor adherence to treatment and the second to concurrent administration of rifampin. From the start of maintenance treatment, the estimated 1-year survival rate was 73.0% (95% CI, 67.5%-77.9%). Five patients discontinued treatment because of suspected drug toxicity, three of whom had possible or probable hepatotoxicity. Median serum and urine HPA levels declined significantly during treatment. The only patient in whom antigen levels rose >2 U developed clinical relapse 1 week later; antigen levels were unavailable in the other relapsing patient.

CONCLUSIONS

Itraconazole, 200 mg daily, is effective in preventing relapse of disseminated histoplasmosis in patients with AIDS. It is generally well tolerated, but clinicians should be alert for drug interactions and possible hepatotoxicity.

Treatment of histoplasmosis with fluconazole in patients with acquired immunodeficiency syndrome. National Institute of Allergy and Infectious Diseases Acquired Immunodeficiency Syndrome Clinical Trials Group and Mycoses Study Group

PURPOSE

This study assesses the efficacy and safety of fluconazole therapy in patients with acquired immunodeficiency syndrome (AIDS) and mild to moderately severe manifestations of disseminated histoplasmosis.

PATIENTS AND METHODS

This was a multicenter, open-label, nonrandomized prospective trial. All patients had AIDS and disseminated histoplasmosis. Patients were treated with 1,200 mg of fluconazole given by mouth once on the first day, then 600 mg once daily for 8 weeks, and those patients who improved clinically were then assigned fluconazole maintenance therapy 200 mg once daily for at least 1 year. Interim analysis revealed a high failure rate (10 of 20, 50%), causing revision of the protocol to increase the fluconazole dose to 1,600 mg given once on the first day, then 800 mg once daily, and the duration to 12 weeks for induction therapy and then 400 mg daily for 1 year for maintenance therapy.

MEASUREMENTS AND MAIN RESULTS

Thirty-six of 49 patients (74%; 95% confidence interval [CI]: 59% to 85%) with mild to moderately severe clinical manifestations who entered into the revised study responded to 800 mg of fluconazole daily for 12 weeks as induction therapy. Of the seven patients who failed induction therapy because of progression of histoplasmosis, one died of the infection. Of 36 patients who entered into the maintenance phase of the study receiving 400 mg of fluconazole daily for 1 year, 11 (30.5%) relapsed, including one who died (2.8%). Two of the 49 patients (4.1%) were removed because of grade 4 adverse events, alkaline phosphatase elevation for one and aspartate aminotransferase elevation in the other. The relapse-free rate at 1 year was 53% (95% CI: 32% to 89%), prompting closure of the study.

CONCLUSIONS

Fluconazole 800 mg daily is a safe and moderately effective induction therapy for mild or moderately severe disseminated histoplasmosis in patients with AIDS. On the basis of historic comparison, fluconazole 400 mg daily is less effective than itraconazole 200 to 400 mg daily or amphotericin B 50 mg given weekly as maintenance therapy to prevent relapse.

Phase I dose-escalation pharmacokinetics of AZT-P-ddI (IVX-E-59) in patients with human immunodeficiency virus

3'-Azido-3'-deoxythymidilyl-(5',5')-2',3'-dideoxy-5'-inosinic acid (AZT-P-ddI, IVX-E-59, Scriptene) is a heterodimer composed of one molecule of 3'-azido-3'-deoxythymidine (zidovudine or AZT) and one molecule of 2',3'-dideoxyinosine (didanosine or ddI) linked through their 5' positions by a phosphate bond. AZT-P-ddI exhibits enhanced antiviral activity and selectivity in vitro compared with AZT and ddI alone. The pharmacokinetics of AZT-P-ddI were studied in 12 patients with human immunodeficiency virus (HIV) who had CD4+ cell counts higher than 200 cells/mm3. Isotopic preparations of (14C)-AZT-P-(3H)-ddI were administered intravenously (50 mg and 100 mg) to eight patients; 1 month later these patients were crossed over to oral administration (100 mg and 200 mg). A second group of patients (n = 4) received only a 450-mg oral dose of AZT-P-ddI. Plasma levels of unchanged AZT-P-ddI after intravenous infusion declined rapidly and were undetectable 0.75 hours after the end of infusion, whereas the parent compound was not detected after oral administration, indicative of a very rapid metabolism. The parent entity was enzymatically cleaved in vivo yielding the two constituent drugs AZT and ddI, which were subsequently subjected to their respective pharmacokinetic and metabolic processes. The beta-glucuronide derivative of AZT (GAZT) represented the major metabolite of AZT, but there were no detectable levels of the toxic metabolite 3'-amino-3'-deoxythymidine (AMT). A major and previously unrecognized in vivo metabolite of ddI, referred as ddI-M, was detected in plasma and urine. Analysis by high-field proton nuclear magnetic resonance and mass spectrometry led to the identification of ddI-M as being R(-)-dihydro-5-(hydroxymethyl)-2(3H)-furanone. The formation of AZT and ddI metabolites was increased after oral administration of AZT-P-ddI compared with the intravenous infusion, with an area under the concentration-time curve (AUC) ratio of metabolite to AZT and metabolite to ddI being 7.7 and 5.7 (oral) and 3.8 and 1.1 (intravenous), respectively. The newly identified ddI-M exhibited sustained plasma levels for extended time periods with an apparent elimination half-life (t1/2) of approximately 10 hours after oral administration of AZT-P-ddI. Recovery of radioactivity associated with 3H and 14C in urine was essentially complete within 48 hours after oral and intravenous administration of AZT-P-ddI. The oral bioavailability of AZT (64.7-67.3%) and ddI (33.6-42.9%) and the other pharmacokinetic parameters were consistent with previous data reported with each nucleoside analog alone or in combination therapy.

Dramatic decrease in tuberculin skin test conversion rate among employees at a hospital in New York City

BACKGROUND

The Centers for Disease Control and Prevention recently issued updated guidelines for preventing the transmission of tuberculosis in health care facilities. Many recommendations, including the use of high-efficiency particulate air filter respirators, are expensive to implement and of unproven efficacy. We therefore reviewed the tuberculin skin test conversion rate among our employees from 1991 to 1993, before introduction of high-efficiency particulate air filter respirators. During this period, several other improvements in tuberculosis control were implemented.

METHODS

Employee tuberculin test conversion rates were reviewed by 6-month interval from 1991 to 1993.

RESULTS

Throughout the study period, several tuberculosis control measures were implemented, including early isolation of patients with suspected cases of tuberculosis in rooms with negative-pressure ventilation, placement of germicidal UV light fixtures into patient rooms and common areas, and use of Technol shields (Technol, Inc., Fort Worth, Texas) (1991), particulate respirators (1992), and dust-mist-fume respirators (1993). With these improvements, the conversion rate among employees fell from 20.7% in the first 6 months of 1991 to 5.8% in the latter half of 1993.

CONCLUSIONS

The rate of skin test conversion among our employees decreased before introduction of high-efficiency particulate air filter respirators. This suggests that nosocomial spread of tuberculosis can be decreased by means of previously established, less costly methods.

Population pharmacokinetics of stavudine (d4T) in patients with AIDS or advanced AIDS-related complex

The population pharmacokinetics and bioavailability of oral stavudine (d4T; 2',3'-dideoxy-3'-deoxythymidine) was determined in 81 patients with AIDS or AIDS-related complex (ARC) enrolled in phase I and phase I/II dose-ranging trials. Each patient underwent inpatient pharmacokinetic studies following administration of the first oral stavudine dose; 59 patients were restudied after chronic therapy for an average of 19 days. Thirty-three of these patients also received a single intravenous stavudine dose prior to starting an oral regimen. A two-compartment model with first-order absorption and elimination was used as the structural pharmacokinetic model. A basic model provided the following population parameter estimates (interpatient variability expressed in parentheses as percent coefficient of variation): clearance/bioavailability = 30.9 (24.5%) liters/h; volume of distribution/bioavailability = 8.42 (not modeled) liters; volume of distribution at steady state/bioavailability = 68.9 (105%) liters; intercompartmental clearance/bioavailability = 12.4 (26%) liters/h; and first-order absorption rate constant = 1.32 (78.9%) liters/h. In the subset of 33 patients receiving both intravenous and oral doses, the bioavailability of stavudine was estimated to be 99.1% (18.5%). Total body weight, stage of disease (AIDS versus ARC), and an oral stavudine dose of > or = 200 mg were found to have a statistically significant but a clinically marginal effect on the estimate of the oral clearance of stavudine. This analysis shows the high degree of bioavailability of stavudine in patients with AIDS and ARC and the relatively low degree of interpatient variability in oral drug clearance compared with those of other nucleosides. Population pharmacokinetic analysis is a useful tool for assessing the combined effects of several patient variables on the pharmacokinetic properties of drugs in human immunodeficiency virus-infected patients.

Pharmacokinetic, safety, and antiviral profiles of oral ganciclovir in persons infected with human immunodeficiency virus: a phase I/II study. AIDS Clinical Trials Group, and Cytomegalovirus Cooperative Study Group

A phase I/II study evaluated the pharmacokinetics, tolerability, and antiviral activity of oral ganciclovir in persons infected with human immunodeficiency virus (HIV). Oral bioavailability ranged from 2.6% to 7.3%. The mean maximum serum concentration achieved at 1000 mg every 8 h was 1.11 micrograms/mL, and mean trough level was 0.54 microgram/mL. The time to maximum serum drug concentration was 1.0-2.9 h, with a serum half-life of 3.0-7.3 h, suggesting prolonged oral absorption. Serious adverse events were uncommon. Decreased cytomegalovirus (CMV) shedding was observed from all sites. The median days (by dosage) to retinitis progression assessed by retinal examination after initiation of oral ganciclovir were 62 (1000 mg every 8 h), 148 (500 mg every 3 h), 75 (750 mg every 3 h), 148 (1000 mg every 3 h), and 139 (2000 mg every 8 h). Thus, oral ganciclovir has pharmacokinetic, toxicity, and antiviral profiles that may prove beneficial for both maintenance therapy of CMV retinitis and prevention of CMV disease in HIV-infected persons.

Multidisciplinary approach used to improve infant care

Many of the implemented changes have required the rewriting of standards of care and policies, as well as the education of staff. Staff education was addressed through a variety of approaches, including one-hour inservice training sessions and eight-hour courses. In the final analysis, the multidisciplinary QA committee has had a significant impact on improving the processes involved in caring for infants with RDS. Because of this success, committee members have acknowledged that all aspects of patient care may be examined and changes implemented when caregivers keep an open mind and are willing to change the way "things have always been done." This commitment to examine all aspects of care and to implement change has been, for Presbyterian Hospital, the key to genuine quality improvement. As a result of these and other efforts, Presbyterian Hospital has improved the care given to all of its patients. In March 1992, the hospital received accreditation with commendation.

Prevention of relapse of histoplasmosis with itraconazole in patients with the acquired immunodeficiency syndrome

OBJECTIVE

To assess the efficacy and safety of itraconazole in preventing relapse of histoplasmosis after induction therapy with amphotericin B in patients with the acquired immunodeficiency syndrome (AIDS) and disseminated histoplasmosis.

DESIGN

A prospective, multicenter, open-label clinical trial, with follow-up for at least 52 weeks.

SETTING

Tertiary care hospitals participating in a clinical investigation sponsored by the National Institutes of Allergy and Infectious Diseases (AIDS Clinical Trial Group and Mycoses Study Group).

PATIENTS

Forty-two patients with AIDS who had successfully completed induction therapy for disseminated histoplasmosis amphotericin B, at least 15 mg/kg body weight given over 4 to 12 weeks.

INTERVENTIONS

Itraconazole, 200 mg given orally twice daily.

MAIN OUTCOME MEASURES

Response to therapy, specifically prevention of histoplasmosis relapse, was the main outcome measure. Secondary end points were survival and the effect of therapy on Histoplasma capsulatum variety capsulatum antigen levels in urine and serum. Plasma itraconazole concentrations were measured to document drug absorption and compliance with therapy.

RESULTS

The median follow-up was 109 weeks, and median survival was 98 weeks. Two relapses occurred (5%; 95% CI, 0.5% to 16%), one in a patient withdrawn from the study 18 weeks earlier and one in a patient who did not comply with the study therapy. Patients with elevated antigen levels at study entry showed clearance of antigen from urine and serum; urine specimens became negative in 43% of patients (CI, 26% to 59%), and serum specimens became negative in 75% of patients (CI, 56% to 94%). Only one patient discontinued treatment because of itraconazole toxicity (hypokalemia).

CONCLUSIONS

Itraconazole, 200 mg twice daily, is safe and effective in preventing relapse of disseminated histoplasmosis in patients with AIDS. Antigen clearance from blood and urine correlates with clinical efficacy.

Fluconazole compared with ketoconazole for the treatment of Candida esophagitis in AIDS. A randomized trial

OBJECTIVE

To determine the clinical and endoscopic response of candida esophagitis to antifungal therapy and to compare the two oral antifungal agents, fluconazole and ketoconazole.

DESIGN

Multicenter, randomized, double-blind trial.

SETTING

Fifteen U.S. centers including university, private practice, and county hospital settings.

PATIENTS

A total of 169 patients with the acquired immunodeficiency syndrome (AIDS); odynophagia, dysphagia, or retrosternal pain; white esophageal plaques at endoscopy; and pseudohyphae on esophageal brushings or biopsies.

INTERVENTION

Patients were randomly assigned to fluconazole (100 mg/d) or ketoconazole (200 mg/d). Doses were doubled at week 1 or 2 if no symptomatic improvement had occurred during the preceding week. Therapy was continued for 2 weeks after resolution of symptoms or for a maximum of 8 weeks.

MEASUREMENTS

Patients were clinically evaluated weekly, and laboratory tests were done every 2 weeks. Endoscopy was repeated within 5 days after the end of therapy.

RESULTS

A total of 143 patients were clinically evaluable (assessed within 7 days after therapy), and 129 patients were endoscopically evaluable (endoscopy repeated after therapy). Endoscopic cure occurred in 91% of patients treated with fluconazole and in 52% of those given ketoconazole for a difference of 39% (95% Cl, 24% to 52%; P less than 0.001). Esophageal symptoms resolved in 85% of fluconazole-treated patients and in 65% of ketoconazole-treated patients for a difference of 20% (Cl, 6% to 34%; P = 0.006). Intention-to-treat analyses also yielded statistically significant differences for the comparisons listed above. Side effects were minimal and comparable in the two groups; only one patient in each group had therapy discontinued for adverse effects that were possibly related to the study medications.

CONCLUSIONS

Fluconazole is associated with significantly greater rates of endoscopic and clinical cure than ketoconazole in patients with AIDS and candida esophagitis. Both drugs appear to be safe and well tolerated.

Widespread intradermal accumulation of mononuclear leukocytes in lepromatous leprosy patients treated systemically with recombinant interferon gamma

Intradermal administration of recombinant interferon gamma (rIFN-gamma) to lepromatous leprosy patients has converted the local histology toward a tuberculoid pattern. However, such changes have been confined to the site of injection. In contrast, in the present study, marked, intradermal accumulation of CD3+, CD4+, CD8+, and CD1a+ T cells and Leu-M5+ mononuclear phagocytes was induced at a distance from the sites of administration, in a dose-dependent manner, by 10 daily intramuscular injections of 10-30 micrograms rIFN-gamma/m2. Mononuclear cell infiltration began within 3 d of onset of rIFN-gamma therapy and persisted at least 8 wk. Intramuscular administration of rIFN-gamma to lepromatous patients receiving concurrent chemotherapy can safely induce widespread histologic features of an upgrading reaction.

Distribution of auditory brainstem potentials over the scalp and nasopharynx in humans

Auditory brainstem potentials were recorded from various scalp and nasopharyngeal sites referenced both to a noncephalic site and to certain scalp locations in normal humans. The distribution of amplitudes and latencies of the components were defined. There were significant amplitude, polarity, and latency asymmetries over the scalp in both referential and differential recordings. The data indicated that several of the ABR components have generator sources that are lateralized and move through the brainstem in particular orientations.