Towards high-quality peri-operative care: a global perspective

Article 25 of the United Nations' Universal Declaration of Human Rights enshrines the right to health and well-being for every individual. However, universal access to high-quality healthcare remains the purview of a handful of wealthy nations. This is no more apparent than in peri-operative care, where an estimated five billion individuals lack access to safe, affordable and timely surgical care. Delivery of surgery and anaesthesia in low-resource environments presents unique challenges that, when unaddressed, result in limited access to low-quality care. Current peri-operative research and clinical guidance often fail to acknowledge these system-level deficits and therefore have limited applicability in low-resource settings. In this manuscript, the authors priority-set the need for equitable access to high-quality peri-operative care and analyse the system-level contributors to excess peri-operative mortality rates, a key marker of quality of care. To provide examples of how research and investment may close the equity gap, a modified Delphi method was adopted to curate and appraise interventions which may, with subsequent research and evaluation, begin to address the barriers to high-quality peri-operative care in low- and middle-income countries.

Twenty-Eight Day Nose-Only Inhalation Toxicity Study of Resorcinol Bis-Diphenylphosphate (Fyrolflex RDP) in Rats

To evaluate the effects of repeated inhalation exposure to resorcinol bis-diphenylphosphate (Fyrolflex RDP), male and female Sprague-Dawley rats received nose-only inhalation exposure to Fyrolflex RDP for 6 h/day, 5 days/week for 4 weeks. Concentrations of Fyrolflex RDP tested were 0 (filtered air control), 0.1, 0.5, and 2.0 mg/l air. Ten rats/sex/group were euthanized on day 29; 10 additional rats/sex in the control and high-dose groups were euthanized after a 60-day recovery period. RDP induced no mortality or overt toxicity during the exposure or recovery periods. Body weight and body weight gain were reduced in high-dose male rats during exposure, but returned to control levels after 5 weeks of recovery. Absolute and relativelung weights were increased in mid-and high-dose groups after exposure, and in the high-dose group at the end of the recovery period. Relative fiver weights were increased after exposure in mid-and high-dose females and in high-dose males. Gross pathology was limited to confluent white foci in the lungs of all high-dose animals after exposure, and in 80 % of high-dose animals after the recovery period. Underlying lung histopathology after exposure consisted of alveolar histiocytosis in mid-and high-dose groups; this progressed to chronic foreign body inflammation in high-dose rats after recovery. This response is characteristic of a noncytotoxic, water-insoluble foreign material that reaches the alveolar region of the lung. On this basis, although the observed lung lesions were exposure-related, they were not considered to reflect a specific toxic response to Fyrolflex RDP. No exposure-relatedgross or microscopic pathology was identified in any other organ in any experimental group. The no-observed-effectlevel (NOEL) for RDP in this study was 0.1 mg/l.

Birth weight and childhood obesity: a 12-country study

OBJECTIVES

Few studies have investigated the association between the full range of birth weight and the risk of childhood obesity in high-, middle- and low-income countries. The aim of the present study is to assess the association between different levels of birth weight and the risk of obesity among children aged 9-11 years in 12 countries.

METHODS

A multinational, cross-sectional study of 5141 children aged 9-11 years was conducted in 12 countries. Height and weight were obtained using standardized methods. Time spent in moderate-to-vigorous physical activity (MVPA), sedentary and sleeping were objectively measured using 24-h, waist-worn accelerometer (Actigraph GT3X+) monitored for 7 days. Birth weight and other factors (regions, parental education, maternal history of gestational diabetes, children age, gender, breast feeding, gestational age, unhealthy diet scores and healthy diet scores) were collected by parental and children's questionnaires. Multilevel modeling was used to account for the nested nature of the data.

RESULTS

The overall prevalence of obesity (BMI z-score>+2 s.d.) was 15.4% for boys and 10.0% for girls. There was a positive association between birth weight and BMI z-scores. The multivariable-adjusted odds ratios (ORs) of childhood obesity were significantly higher among children whose birth weights were 3500-3999 g (OR 1.45; 95% confidence interval (CI): 1.10-1.92), and >4000 g (OR 2.08; 95% CI: 1.47-2.93), compared with the reference group (2500-2999 g). The positive association between birth weight and the odds of childhood obesity was seen in girls, whereas a U-shaped association appeared in boys.

CONCLUSIONS

High levels of birth weight, defined as birth weight ⩾3500 g, were associated with increased odds of obesity among 9-11-year-old children in 12 countries. However, sex differences in the association between birth weight and the risk of obesity need to be considered when planning interventions to reduce childhood obesity.

CD4 deficit and tuberculosis risk persist with delayed antiretroviral therapy: 5-year data from CIPRA HT-001

SETTING

Port-au-Prince, Haiti.

OBJECTIVE

To determine long-term effects of early vs. delayed initiation of antiretroviral therapy (ART) on immune recovery and tuberculosis (TB) risk in human immunodeficiency virus (HIV) infected individuals.

DESIGN

Open-label randomized controlled trial of immediate ART in HIV-infected adults with CD4 counts between 200 and 350 cells/mm(3) vs. deferring ART until the CD4 count was <200 cells/mm(3). The primary comparisons were CD4 counts over time and risk for incident TB, with 5 years of follow-up.

RESULTS

A total of 816 participants were enrolled, with 408 in each treatment arm. The early treatment group started ART within 2 weeks, while the deferred treatment group started ART a median of 1.3 years after enrollment. After 5 years, the mean CD4 count in the early treatment group was significantly higher than in the deferred treatment group (496 cells/mm(3), 95% confidence interval [CI] 477-515 vs. 373 cells/mm(3), 95%CI 357-389; P < 0.0001). TB risk was higher in the deferred treatment group (unadjusted HR 2.41, 95%CI 1.56-3.74; P < 0.0001) and strongly correlated with lower CD4 counts in time-dependent multivariate analysis.

CONCLUSION

Delays in ART initiation for HIV-infected adults with CD4 counts of 200-350 cells/mm(3) can result in long-term immune dysfunction and persistent increased risk for TB.

Low vitamin D levels, prediabetes and prehypertension in healthy African American adults

AIMS

To determine if customary lower serum vitamin D concentrations in healthy African American (AA) adults are associated with modest elevations in fasting plasma glucose (FPG) and/or resting blood pressure (BP). Numerous health disparities between African American (AA) and Caucasian American (CA) adults, especially those which increase cardiovascular morbidity and mortality, have been attributed to lower serum vitamin D concentrations in the AA. Prediabetes (PreDM) and prehypertension (PreHTN) are significantly more prevalent in healthy disease free CA adults with serum vitamin D concentrations below the 75th percentile for the Caucasian cohort. We hypothesized that despite overall lower serum vitamin D concentrations in AA, an increase in the prevalence for PreDM and PreHTN would be seen in those with low vitamin D levels.

METHODS AND RESULTS

Disease free AA adults in the National Health and Nutrition Examination Survey 2001-2006 were assessed. PreDM and PreHTN were diagnosed using the ADA and JNC 7 criteria: (FPG) 100-125 mg/dL and resting systolic (SBP) 120-139 and/or diastolic (DBP) 80-89 mm Hg, respectively. Logistic regression was employed to assess effects of low vitamin D concentrations on the odds for PreDM and PreHTN (n = 621). Age, gender and BMI adjusted odds ratio for co-morbid PreDM and PreHTN in AA men (n = 343) and women (n = 278) with vitamin D levels ≤45.4 versus >45.4 nmol/L was 2.02 (1.11, 3.68), (p < 0.021).

CONCLUSIONS

Evaluating serum vitamin D levels, with consideration for supplementation in seemingly healthy AA adults with prediabetes, prehypertension, or co-existing prediabetes and prehypertension, has merit.

Subchronic oral toxicity and cardiovascular safety pharmacology studies of resveratrol, a naturally occurring polyphenol with cancer preventive activity

To characterize the subchronic oral toxicity of resveratrol, CD rats received daily gavage doses of 0, 200, 400, or 1000 mg resveratrol/kg/day, and beagle dogs received daily capsule doses of 0, 200, 600, or 1200 mg resveratrol/kg/day for 90 days. Resveratrol induced only minimal toxicity, consisting of dose-related reductions in body weight gain in female rats and both sexes of dogs, and a statistically significant increase in bilirubin levels in rats at the 1000 mg/kg/day dose. Clinical observations, hematology, ophthalmology, neurotoxicity evaluations (functional observational batteries), organ weights, and gross pathology provided no biologically significant evidence of resveratrol toxicity in either species. In rats, the high dose of resveratrol reduced the incidence of cardiomyopathy; no other microscopic changes were seen. Histopathologic changes in dogs were limited to minimal inflammatory infiltrates in the kidney and urinary bladder, which were not considered toxicologically significant. A cardiovascular safety pharmacology (telemetry) study in dogs revealed no evidence of resveratrol toxicity. Based on body weight effects, the No Observed Adverse Effect Level (NOAEL) for resveratrol was 200mg/kg/day in rats and 600 mg/kg/day in dogs. The apparent cardioprotective activity of resveratrol in rats demonstrates that its potentially beneficial activities may extend beyond efficacy in cancer prevention.

A SAS program for calculating cumulative incidence of events (with confidence limits) and number at risk at specified time intervals with partially censored data

Correct analysis and interpretation of longitudinal (cohort) studies with partially censored time-to-event data requires that the cumulative count of events and censored observations as well as the number at risk be calculated at appropriate time points (for example, every year), by baseline group or stratum. We present here a simple SAS program, for use in situations in which competing risks do not need to be accounted for, that calculates, by baseline group or stratum, the cumulative event count, cumulative event probability (with upper and lower 95% confidence limits), and number at risk at selected time points that can be chosen by the user. We demonstrate the use of the program in the analysis of longitudinal time-to-event data from a prospective study, the Atherosclerosis Risk In Communities (ARIC) Study, for four groups and a 10-year follow-up. The SAS code presented here is easy to follow and modify and can be incorporated quickly by the user for immediate use. It provides an especially valuable tool for less experienced SAS users.

Subchronic oral toxicity studies of Se-methylselenocysteine, an organoselenium compound for breast cancer prevention

Se-methylselenocysteine (MSC) is an organoselenium compound being developed for breast cancer chemoprevention. To characterize MSC toxicity, CD rats received daily gavage doses of 0, 0.5, 1.0, or 2.0 mg/kg/day (0, 3, 6, or 12 mg/m(2)/day), and beagle dogs received daily gavage doses of 0, 0.15, 0.3, or 0.6 mg/kg/day (0, 3, 6, or 12 mg/m(2)/day) for 28 days. In rats, MSC induced dose-related hepatomegaly in both sexes; mild anemia, thrombocytopenia, and elevated liver enzymes were observed in high dose females only. Microscopic pathology included hepatocellular degeneration (high dose males, all doses in females); arrested spermatogenesis (high dose males); and atrophy of corpora lutea (middle and high dose females). In dogs, MSC induced mild anemia in middle and high dose males, and in high dose females. Toxicologically significant microscopic lesions in dogs were seen only in the liver (peliosis and vacuolar degeneration in high dose males, midzonal necrosis in males in all dose groups). Based on liver pathology seen in female rats in all dose groups, the no observed adverse effect level (NOAEL) for MSC in rats is <0.5mg/kg/day. Based on alterations in hematology parameters and liver morphology in male dogs in all dose groups, the NOAEL for MSC in dogs is <0.15 mg/kg/day.

Interventions to modify sexual risk behaviors for preventing HIV infection in men who have sex with men

BACKGROUND

MSM remain at great risk for HIV infection. Program planners and policy makers need descriptions of interventions and quantitative estimates of intervention effects to make informed decisions concerning prevention efforts.

OBJECTIVES

1. To locate and describe outcome studies evaluating the effects of behavioral and social interventions targeting MSM. 2. To summarize the effectiveness of these interventions among MSM. 3. To stratify results by characteristics of interventions and participants. 4. To identify gaps and indicate future research, policy, and practice needs.

SEARCH STRATEGY

We searched electronic databases (MedLine, PsycInfo, etc.); several current journals (e.g., AIDS, AIDS and Behavior, AIDS Education and Prevention, American Journal of Public Health, Journal of Acquired Immune Deficiency Syndromes, etc.); manuscripts submitted by researchers; bibliographies of relevant articles; and other published reviews, for published and unpublished reports from 1988 through 1997.

SELECTION CRITERIA

Studies were considered in scope if they examined the effects of behavioral interventions to reduce risk for HIV or STD transmission. We reviewed studies in scope for criteria of outcome relevance (measurement of at least one of a list of behavioral or biologic outcomes, e.g., unprotected sex or incidence of HIV infections) and methodologic rigor (randomized controlled trials or certain strong quasi-experimental designs with comparison groups).

DATA COLLECTION AND ANALYSIS

As of June 1998 we had identified 13 eligible studies. Twelve studies (7 trials of small group interventions, 3 community-level interventions, and 2 individual level interventions) reported intervention effects on unprotected sex. Because few studies reported effects on condom use (3 studies), number of sex partners without regard to condom use (4 studies), or HIV or STD incidence (1 study in which no infections occurred) we do not address these outcomes at this time. We present those analyses which can be performed in the current Cochrane RevMan software, followed by more complete analyses that permit inclusion of community-level studies, adjustment for baseline conditions, calculation of effect sizes from a wider variety of statistics (e.g., an F-statistic from a one-way ANOVA), and simultaneous meta-analysis of continuous and dichotomous outcomes (Johnson 2002b). We translate the summary effect to reduction in risk behavior based on the background prevalence of unprotected sex. Finally we provide analyses stratified by intervention content (interpersonal skills addressed or not), intervention format (community vs small group or individual) and mean age of participants (23 to 31 vs. 32 to 36).

MAIN RESULTS

A summary measure of intervention effects on reducing unprotected sex was favorable (odds ratio = 0.73) and statistically significant (CI, 0.60 to 0.88), corresponding to a 23% reduction in the proportion of men engaging in unprotected sex. Effects were homogeneous among studies, but were slightly more favorable among community-level interventions, those that served populations in their 20s rather than their 30s, and those that promoted interpersonal skills.

REVIEWER'S CONCLUSIONS

These studies demonstrate that interventions can promote risk reduction among MSM. Yet given the epidemiology of HIV in Pattern I countries, the small number of rigorous controlled intervention trials for this population is striking. Many more rigorous evaluations of HIV prevention efforts with MSM are needed to ascertain with confidence the effects of specific intervention components, population characteristics, and methodologic features.

Absence of Chlamydia pneumoniae in surgical specimens of coronary and carotid arteries by polymerase chain reaction

PURPOSE

Several recent articles indicate the renewed interest that Chlamydia pneumoniae is associated with and contributes to arterial diseases. Associations have been established for coronary arteries, carotid arteries and abdominal aortic aneurysms by serological studies, immunofluorescence and DNA-specific testing. The purpose of this study was to determine the presence of C. pneumoniae in coronary artery plaques, carotid artery plaques and old vein grafts that were harvested at the time of surgery.

METHODS AND MATERIALS

Interventions were carried out on patients with carotid artery disease and coronary disease based upon their anatomic findings and symptomatology. Plaques were removed from the carotid arteries with standard endarterectomy techniques. The coronary plaques were removed utilizing blunt dissection to peel the plaque from the coronary artery. Old vein grafts were harvested during repeat surgery by excising the vein grafts. The tissue specimens were analyzed by polymerase chain reaction (PCR).

RESULTS

Ninety-nine specimens from 68 consecutive patients with advanced coronary atherosclerosis with or without cerebrovascular disease were analyzed. We failed to find C. pneumoniae in any of the vascular tissue.

CONCLUSIONS

A large cooperative study involving surgical specimen analysis is needed to assess the role of C. pneumoniae in the etiology of atherosclerosis.

Integration of tuberculosis screening at an HIV voluntary counselling and testing centre in Haiti

OBJECTIVE

To describe the integration of tuberculosis screening into the activities of an HIV voluntary counselling and testing (VCT) centre in a country with endemic tuberculosis.

SETTING

An HIV VCT centre in Port au Prince, Haiti.

DESIGN

All patients presenting for HIV VCT who reported cough received same-day evaluation for active tuberculosis. Of the 1327 adults presenting to the centre for the first time between January and April 1997, 263 (20%) reported cough and of these 241 (92%) were evaluated.

RESULTS

Of the 241 patients evaluated for cough, 76 (32%) were diagnosed with pulmonary tuberculosis. Of the 76 patients diagnosed with pulmonary tuberculosis, 28 (37%) had a positive smear for acid-fast bacilli (AFB), 14 (18%) had a negative AFB smear but a positive sputum culture for Mycobacterium tuberculosis, and 34 (45%) had culture-negative tuberculosis. Also, 31 out of 241 (13%) VCT clients evaluated for cough were diagnosed with bacterial pneumonia.

CONCLUSION

This report confirms that in areas with a high HIV and tuberculosis prevalence, a high proportion of VCT clients have active pulmonary tuberculosis. The integration of tuberculosis screening offers several benefits, including the diagnosis and treatment of large numbers of individuals with tuberculosis, a decreased risk of nosocomial tuberculosis transmission, and the opportunity to provide tuberculosis prophylaxis to HIV-positive patients in whom tuberculosis has been excluded. Future studies are needed to determine the cost-effectiveness of integrated tuberculosis and HIV VCT services, and whether integration should be recommended in all countries with high HIV and tuberculosis rates.

History of hydrocephalus and its treatments

Hydrocephalus has amazed and challenged clinicians throughout the history of medicine. In reviewing the treatment of hydrocephalus, the integral relationship between basic science and therapy is reaffirmed. As we embark into a new millennium, it is appropriate to reflect on the past studies of this disorder, review various attempted and currently used, and finally speculate on possible future directions in its treatment.

Helicobacter pylori-associated gastritis and the ascorbic acid concentration in gastric juice

Patients infected with Helicobacter pylori have abnormally low ascorbic acid concentration in gastric juice. Low vitamin C intake and Helicobacter pylori infection have been related to an increased risk of gastric carcinoma. This report examines the association between ascorbic acid and Helicobacter pylori in patients referred for upper gastrointestinal endoscopy. Elevated gastric pH and the damage to the gastric surface epithelium were inversely associated with the ascorbic acid concentration in gastric juice. We postulate that these two factors mediate the ascorbic acid-decreasing effect of Helicobacter pylori. Patients with nonpremalignant conditions (normal gastric histology, diffuse antral gastritis, or duodenal ulcer) had lower gastric pH, less damage to the gastric epithelium, and higher levels of ascorbic acid in gastric juice than patients with atrophic gastritis, intestinal metaplasia, or dysplasia.

IS1245 genotypic analysis of Mycobacterium avium isolates from patients in Brazil

OBJECTIVE

Disseminated Mycobacterium avium infection is an emerging opportunistic disease among patients with acquired immunodeficiency syndrome (AIDS) in Brazil. The mode of transmission of M. avium in a developing country setting needs to be better characterized.

METHODS

Mycobacterium avium strain collections in São Paulo and Rio de Janeiro were analyzed according to the strains' IS1245 DNA gel electrophoretic migration patterns. Medical records of the patients from whom M. avium isolates were available were reviewed, and their demographic characteristics were stratified according to the isolates' IS1245 DNA fingerprint patterns.

RESULTS

Of 105 patients, 33 (31%) with M. avium isolated between 1990 and 1994 had strains having IS1245 patterns identical in patterns seen in isolates from two or more patients (designated as cluster pattern strains). Cluster pattern strains were isolated from 21 (39%) of 54 patients with disseminated infection (defined as infection due to M. avium isolated from a sterile site in an adult patient). Six of the cluster pattern strains were isolated only from sterile sites. In São Paulo, cluster pattern strains were significantly more likely to be isolated from patients with disseminated disease.

CONCLUSIONS

These preliminary observations suggest that in large cities of Brazil, a high proportion (at least 39%) of disseminated M. avium infections in patients with AIDS results from a recent transmission. Some strains of M. avium may be more likely to cause disseminated disease than others after an infection.

Symmetry in square contingency tables: tests of hypotheses and confidence interval construction

Bowker's test, a generalization of McNemar's test, performs well under the hypothesis of symmetry, but the estimator of variance used in the test is biased when the table is asymmetric and this calls into question the test's performance in non-null situations. We seek an alternative to Bowker's test in search of methods for simultaneous inference that are valid when the hypothesis of symmetry is false. We apply multivariate normal theory to develop chi-square tests and simultaneous confidence intervals for inferences concerning symmetry in k X k contingency tables. We propose a modified Wald statistic as a competitor to Bowker's test. We also proffer quadratic estimators of confidence intervals. In large samples, the recommended test statistic rejects the null hypothesis at the stated level of significance when the null hypothesis is true and always rejects with greater power than Bowker's test. The proffered interval estimators provide good simultaneous coverage of the pairwise differences between the population proportions at the stated confidence level.

Adequacy of fellowship training: results of a survey of recently graduated fellows

The adequacy of fellowship training in the field of infectious diseases was assessed by means of a survey of recently graduated fellows. Surveys were mailed to all individuals who had passed the American Board of Internal Medicine's board certification examination in infectious diseases since 1992. A total of 666 completed surveys were returned by the deadline (response rate, 36%). Although most recent graduates thought that training in the standard components of clinical infectious diseases was adequate, only 50% thought that training in infection control was adequate. Fewer than 1 in 3 believed that they had received adequate training in the business aspects of infectious diseases practice. The adequacy and duration of research training were linked to ultimate career choice. These results form the basis for the Infectious Diseases Society of America's new initiatives to assist with more-diversified and relevant fellowship training.

A venue-based method for sampling hard-to-reach populations

Constructing scientifically sound samples of hard-to-reach populations, also known as hidden populations, is a challenge for many research projects. Traditional sample survey methods, such as random sampling from telephone or mailing lists, can yield low numbers of eligible respondents while non-probability sampling introduces unknown biases. The authors describe a venue-based application of time-space sampling (TSS) that addresses the challenges of accessing hard-to-reach populations. The method entails identifying days and times when the target population gathers at specific venues, constructing a sampling frame of venue, day-time units (VDTs), randomly selecting and visiting VDTs (the primary sampling units), and systematically intercepting and collecting information from consenting members of the target population. This allows researchers to construct a sample with known properties, make statistical inference to the larger population of venue visitors, and theorize about the introduction of biases that may limit generalization of results to the target population. The authors describe their use of TSS in the ongoing Community Intervention Trial for Youth (CITY) project to generate a systematic sample of young men who have sex with men. The project is an ongoing community level HIV prevention intervention trial funded by the Centers for Disease Control and Prevention. The TSS method is reproducible and can be adapted to hard-to-reach populations in other situations, environments, and cultures.

A novel approach to directly observed therapy for tuberculosis in an HIV-endemic area

OBJECTIVES

This study evaluated a novel approach to the delivery of directly observed therapy (DOT) for tuberculosis in Haiti.

METHODS

A total of 194 patients (152 HIV seropositive, 42 HIV seronegative) received daily unsupervised triple-drug therapy for 4 to 8 weeks, followed by twice-weekly 2-drug therapy for the remainder of the 6-month period. DOT was deferred until initiation of the twice-weekly phase.

RESULTS

A total of 169 of 194 patients (87.1%) completed the 6-month course. The program of deferred DOT had an effectiveness of 85%. Overall cost was reduced by approximately 40%.

CONCLUSIONS

Flexible approaches to DOT, integrating behavioral knowledge, cost considerations, and practicality may improve completion rates and program effectiveness.

Chemoprevention of gastric dysplasia: randomized trial of antioxidant supplements and anti-helicobacter pylori therapy

BACKGROUND

Previous research has identified a high risk of gastric carcinoma as well as a high prevalence of cancer precursor lesions in rural populations living in the province of Nariño, Colombia, in the Andes Mountains.

METHODS

A randomized, controlled chemoprevention trial was conducted in subjects with confirmed histologic diagnoses of multifocal nonmetaplastic atrophy and/or intestinal metaplasia, two precancerous lesions. Individuals were assigned to receive anti-Helicobacter pylori triple therapy and/or dietary supplementation with ascorbic acid, beta-carotene, or their corresponding placebos. Gastric biopsy specimens taken at baseline were compared with those taken at 72 months. Relative risks of progression, no change, and regression from multifocal nonmetaplastic atrophy and intestinal metaplasia were analyzed with multivariate polytomous logistic regression models to estimate treatment effects. All statistical tests were two-sided.

RESULTS

All three basic interventions resulted in statistically significant increases in the rates of regression: Relative risks were 4.8 (95% confidence interval [CI] = 1.6-14.2) for anti-H. pylori treatment, 5. 1 (95% CI = 1.7-15.0) for beta-carotene treatment, and 5.0 (95% CI = 1.7-14.4) for ascorbic acid treatment in subjects with atrophy. Corresponding relative risks of regression in subjects with intestinal metaplasia were 3.1 (95% CI = 1.0-9.3), 3.4 (95% CI = 1.1-9.8), and 3.3 (95% CI = 1.1-9.5). Combinations of treatments did not statistically significantly increase the regression rates. Curing the H. pylori infection (which occurred in 74% of the treated subjects) produced a marked and statistically significant increase in the rate of regression of the precursor lesions (relative risks = 8.7 [95% CI = 2.7-28.2] for subjects with atrophy and 5.4 [95% CI = 1.7-17.6] for subjects with intestinal metaplasia).

CONCLUSIONS

In the very high-risk population studied, effective anti-H. pylori treatment and dietary supplementation with antioxidant micronutrients may interfere with the precancerous process, mostly by increasing the rate of regression of cancer precursor lesions, and may be an effective strategy to prevent gastric carcinoma.

Active tuberculosis in individuals infected with human immunodeficiency virus after isoniazid prophylaxis

A review was conducted in Haiti to determine the timing and outcome of active tuberculosis (TB) in human immunodeficiency virus (HIV)-positive patients who had previously received isoniazid (INH) prophylaxis. Of 1005 HIV-seropositive patients who completed INH prophylaxis, 14 (1.4%) subsequently had active TB diagnosed. The median interval between discontinuation of INH prophylaxis and TB diagnosis was 8 months for 6 patients receiving 6 months of INH, 22 months for 5 patients receiving 12-24 months of INH, and 40 months for 3 patients receiving 24-36 months of INH (P = .026). There is a postprophylaxis effect on INH that is dependent upon the duration of therapy.

HIV infection in Haiti: natural history and disease progression

OBJECTIVE

A study was conducted to define the natural history and disease progression of HIV infection in a developing country.

DESIGN

A prospective longitudinal cohort study.

METHODS

Forty-two patients with documented dates of HIV seroconversion were followed in Port-au-Prince, Haiti. Patients were seen at 3 month intervals or when ill. Patients were treated for bacterial, mycobacterial, parasitic, and fungal infections, but antiretroviral therapy was not available. Patients were followed until death or until 1 January 2000; median follow-up was 66 months.

RESULTS

By Kaplan-Meier analyses, the median time to symptomatic HIV disease (CDC category B or C) was 3.0 years [95% confidence interval (CI) 2.3-5.0 years]. The median time to AIDS (CDC category C) was 5.2 years (95% CI 4.7-6.5 years), and the median time to death was 7.4 years (95% CI 6.2-10.2 years). Community-acquired infections, including respiratory tract infections, acute diarrhea, and skin infections were common in the pre-AIDS period. AIDS-defining illnesses included tuberculosis, wasting syndrome, cryptosporidiosis, cyclosporiasis, candida esophagitis, toxoplasmosis, and cryptococcal meningitis. Rapid progression to death was associated with anemia at the time of seroconversion hazards ratio (HR) 4.1 (95% CI 1.1-15.0), age greater than 35 years at seroconversion HR 4.4 (95% CI 1.1-16.6), and lymphopenia at seroconversion HR 11.0 (95% CI 2.3-53.0).

CONCLUSION

This report documents rapid disease progression from HIV seroconversion until death among patients living in a developing country. Interventions, including nutritional support and prophylaxis of common community-acquired infections during the pre-AIDS period may slow disease progression and prolong life for HIV-infected individuals in less-developed countries.

Effect of post-treatment isoniazid on prevention of recurrent tuberculosis in HIV-1-infected individuals: a randomised trial

BACKGROUND

Patients with HIV-1 infection respond well to treatment for active tuberculosis, but whether such patients are at increased risk of disease recurrence after complete cure is uncertain. We did a randomised trial in Port au Prince, Haiti, to determine whether recurrent tuberculosis after curative tuberculosis treatment is more common in HIV-1-infected individuals than HIV-1-uninfected individuals, and to determine whether post-treatment isoniazid prophylaxis decreases the risk of recurrent tuberculosis.

METHODS

Patients older than 18 years who were diagnosed with a first episode of tuberculosis at the national HIV testing centre in Haiti, and who successfully completed a 6-month rifampicin-containing regimen for active pulmonary tuberculosis, were randomly assigned 1 year of post-treatment isoniazid prophylaxis or placebo. The primary outcome measure was rate of recurrent tuberculosis after at least 24 months. An intention-to-treat analysis was used.

FINDINGS

Of 354 patients with active pulmonary tuberculosis, 274 successfully completed treatment, and 233 were randomised. Of 142 HIV-1-positive patients, 68 were assigned isoniazid and 74 placebo. Of 91 HIV-1-negative individuals, 51 were assigned isoniazid and 40 placebo. The rate of recurrent tuberculosis was 4.8 per 100 person-years in HIV-1-infected individuals and 0.4 per 100 person-years in uninfected individuals (relative risk 10.7 [95% CI 1.4-81.6]). Among HIV-1-positive patients receiving isoniazid, the tuberculosis recurrence rate was 1.4 per 100 person-years, and among HIV-1-positive patients receiving placebo, it was 7.8 per 100 person-years (0.18 [0.04-0.83]). Among HIV-1-positive individuals, all cases of recurrent tuberculosis occurred in individuals with a history of HIV-1-related symptoms before initial tuberculosis diagnosis.

INTERPRETATION

The rate of recurrent tuberculosis is higher in HIV-1-positive individuals than in HIV-1-negative individuals, and is strongly associated with a history of symptomatic HIV-1 disease before initial tuberculosis diagnosis. Post-treatment isoniazid prophylaxis decreases the risk of recurrence in HIV-1-positive individuals, and should be considered for HIV-1-positive individuals with a history of HIV-1-related symptoms at the time of tuberculosis diagnosis.

Trimethoprim-sulfamethoxazole compared with ciprofloxacin for treatment and prophylaxis of Isospora belli and Cyclospora cayetanensis infection in HIV-infected patients. A randomized, controlled trial

BACKGROUND

In developing countries, Isospora belli and Cyclospora cayetanensis frequently cause chronic diarrhea in HIV-infected patients.

OBJECTIVE

To compare 1 week of trimethoprim-sulfamethoxazole treatment and 1 week of ciprofloxacin treatment in HIV-infected patients with chronic diarrhea caused by I. belli and C. cayetanensis.

DESIGN

Randomized, controlled trial.

SETTING

HIV clinic in Port-au-Prince, Haiti.

PATIENTS

42 HIV-infected patients with chronic diarrhea due to I. belli (n = 22) or C cayetanensis (n = 20).

INTERVENTIONS

Patients were randomly assigned to receive oral trimethoprim-sulfamethoxazole (160 mg or 800 mg) or ciprofloxacin (500 mg) twice daily for 7 days. Patients who responded clinically and microbiologically received prophylaxis for 10 weeks (1 tablet orally, three times per week).

MEASUREMENTS

Treatment success was measured by cessation of diarrhea and negative stool examination at day 7. Prophylaxis success was measured by recurrent disease rate.

RESULTS

Diarrhea ceased in all 19 patients treated with trimethoprim-sulfamethoxazole. Eighteen of 19 patients had negative results on stool examination at day 7 (95%). Among the 23 patients who received ciprofloxacin, diarrhea ceased in 20 (87% [CI; 66% to 97%]) and 16 had negative results on stool examination at day 7 (70%). By survival analysis, diarrhea from isosporiasis and cyclosporiasis ceased more rapidly with trimethoprim-sulfamethoxazole than with ciprofloxacin. All patients receiving secondary prophylaxis with trimethoprim-sulfamethoxazole remained disease-free, and 15 of 16 patients receiving secondary prophylaxis with ciprofloxacin remained disease-free.

CONCLUSIONS

A 1-week course of trimethoprim-sulfamethoxazole is effective in HIV-infected patients with cyclosporiasis or isosporiasis. Although ciprofloxacin is not as effective, it is acceptable for patients who cannot tolerate trimethoprim-sulfamethoxazole.

The left atrial appendage: our most lethal human attachment! Surgical implications

OBJECTIVES

To prevent death from atrial fibrillation, a cardiac disease which kills by producing emboli. Atrial fibrillation causes about 25% of strokes and increases stroke rate by five times. Over 90% of these embolic strokes are from clots originating in the left atrial appendage. This study addresses the surgical feasibility of removing the appendage to prevent future deaths in two subcategories of patients. (1) Prophylactic removal during open-heart surgery to study its safety. Theoretically, as these patients age and some develop atrial fibrillation, protection from embolic strokes would already be present. (2) Therapeutic removal in chronic atrial fibrillation patients by means of a thorascopic approach. Its technical feasibility is demonstrated. Its actual stroke prevention potential awaits large studies.

METHODS

Appendectomy has been evaluated three ways. (1) Experimentally, thorascopic appendage removal was performed on 20 goats with endoscopic approach. Late studies showed a cleanly healed atrial closure after stapling, and no puckering of tissue as seen with the purse-string approach. (2) Safety of human appendectomy was demonstrated in 437 patients (1995-1997). Routine appendectomy was performed during open-heart surgery. Forty-three appendages were stapled, 391 sutured off. (3) Thorascopic appendectomy in seven patients with chronic atrial fibrillation has been successfully accomplished as an isolated surgical procedure. Stapling or suture closure provides a much cleaner, non-puckered suture line than a purse string.

RESULTS

In prophylactic removal, no acute bleeding occurred. No late problems have been identified. Endoscopic removal of the appendage has been successful in seven atrial fibrillation patients.

CONCLUSIONS

The left atrial appendage is a lethal source of emboli in atrial fibrillation patients. As patients age and often develop atrial fibrillation, prophylactic appendage removal whenever the chest is open is suggested as a method to prevent future strokes. In chronic atrial fibrillation patients, appendectomy can be done with a mini-thorascopic approach. Further studies are planned to demonstrate the effectiveness of appendectomy in preventing strokes in the chronic fibrillating patients.

Blood pressure in acute vaso-occlusive crises of sickle cell disease

OBJECTIVE

We compared blood pressure (BP) in patients with sickle cell disease (SCD)-related crises and black patients without SCD.

METHODS

We retrospectively reviewed charts of emergency department (ED) patients with SCD crises in a 2-year period, recording BPs and demographic and SCD data. A cohort of consecutive black patients without SCD was compared.

RESULTS

Included were 459 SCD-related visits, 187 by men and 272 by women, representing 106 patients. Women had significantly lower BP than men, diastolic BP was significantly lower in patients with hemoglobin SS disease than in those with hemoglobin SC disease, and systolic BP was significantly lower in patients with bilateral versus unilateral pain. One SCD patient had a history of hypertension. The 125 non-SCD patients, excluding 25 with a history of hypertension, had significantly higher systolic and diastolic BP than patients in SCD crisis.

CONCLUSION

No patients seen in SCD crisis were hypertensive. Patients who were female, had SS disease, or had bilateral pain had lower BP. Significantly higher BP and more hypertension occurred in black patients without SCD.

Clonally related penicillin-nonsusceptible Streptococcus pneumoniae serotype 14 from cases of meningitis in Salvador, Brazil

Active hospital-based surveillance in the city of Salvador, Brazil, from December 1995 through October 1998, identified 221 patients with confirmed pneumococcal meningitis. Of these 221 patients, 29 (13%) had isolates with intermediate-level resistance to penicillin. Infection with these penicillin-nonsusceptible isolates was significantly associated with age of <2 years (P<.0019), previous antibiotic use (P<.0006), and coresistance to trimethoprim-sulfamethoxazole (P<.0000). Serotype 14 was the most prevalent serotype (55.2%) of penicillin-nonsusceptible isolates. Strain typing by repetitive element BOX polymerase chain reaction (PCR) analysis showed that penicillin-nonsusceptible serotype 14 isolates had closely related BOX PCR patterns, whereas penicillin-susceptible serotype 14 isolates each had distinct, unrelated patterns. Penicillin-nonsusceptible serotype 14 isolates from Salvador and other Brazilian cities had similar BOX PCR patterns. These observations indicate that in Brazil a large proportion of cases of penicillin-nonsusceptible pneumococcal meningitis appear to be caused by a closely related group of serotype 14 strains that may have disseminated to widely separate geographic areas.

Urban epidemic of severe leptospirosis in Brazil. Salvador Leptospirosis Study Group

BACKGROUND

Leptospirosis has, traditionally, been considered a sporadic rural disease. We describe a large urban outbreak of leptospirosis.

METHODS

Active surveillance for leptospirosis was established in an infectious-disease referral hospital in Salvador, Brazil, between March 10 and Nov 2, 1996. Patients meeting case criteria for severe manifestations of leptospirosis were recruited into the study. The diagnosis was confirmed in the laboratory with the microagglutination test and identification of leptospires in blood or urine. Risk factors for death were examined by multivariate analyses.

FINDINGS

Surveillance identified 326 cases of which 193 (59%) were laboratory-confirmed (133) or probable (60) cases. Leptospira interrogans serovar copenhageni was isolated from 87% of the cases with positive blood cultures. Most of the cases were adult (mean age 35.9 years [SD 15.9]), and 80% were male. Complications included jaundice (91%), oliguria (35%), and severe anaemia (26%). 50 cases died (case-fatality rate 15%) despite aggressive supportive care including dialysis (in 23%). Altered mental status was the strongest independent predictor of death (odds ratio 9.12 [95% CI 4.28-20.3]), age over 37 years, renal insufficiency, and respiratory insufficiency were also significant predictors of death. Before admission to hospital, 42% were misdiagnosed as having dengue fever in the outpatient clinic; an outbreak of dengue fever was taking place concurrently.

INTERPRETATION

An epidemic of leptospirosis has become a major urban health problem, associated with high mortality. Diagnostic confusion with dengue fever, another emerging infectious disease with a similar geographic distribution, prevents timely intervention that could minimise mortality.

Chemoprevention of rat prostate carcinogenesis by early and delayed administration of dehydroepiandrosterone

Two in vivo bioassays were conducted to evaluate the efficacy of dehydroepiandrosterone (DHEA) as an inhibitor of prostate carcinogenesis in rats. Prostate adenocarcinomas were induced in male Wistar-Unilever rats by a sequential regimen of cyproterone acetate and testosterone propionate, followed by a single i.v. injection of N-methyl-N-nitrosourea (MNU) and chronic androgen stimulation. In the first experiment, DHEA (1000 or 2000 mg/kg diet) was administered continuously to rats beginning 1 week before MNU exposure. In the second experiment, continuous administration of DHEA (2000 mg/kg diet) was begun either 1 week before, 20 weeks after, or 40 weeks after MNU exposure. Controls received basal diet without added DHEA. Studies were terminated at 13 months after MNU administration, and prostate cancer incidence was determined by histopathological evaluation of step sections of accessory sex glands. In the first study, continuous dietary administration of DHEA beginning 1 week before MNU resulted in a dose-related inhibition of prostate cancer induction. In the second experiment, comparable reductions in prostate cancer incidence were observed in groups exposed to DHEA beginning 1 week before, 20 weeks after, and 40 weeks after carcinogen exposure. These data demonstrate that nontoxic doses of DHEA confer significant protection against prostate carcinogenesis in rats. The efficacy of delayed administration of DHEA suggests that the compound confers protection against later stages of prostate cancer induction and can suppress the progression of existing preneoplastic lesions to invasive disease.

The natural history of human immunodeficiency virus 1 infection in Haitian infants

OBJECTIVES

The current study followed HIV-infected women through pregnancy and their infants through the first 2 years of life to determine the rate of vertical transmission of HIV infection from Haitian women, factors in maternal health and obstetrical history that might influence such transmission and the natural history of HIV infection in their affected offspring.

STUDY DESIGN

The medical histories of 81 infants born of HIV-infected women and of a control group of 88 infants born to uninfected women were documented with close clinical and serologic follow-up. In addition to standard tests for persistence of HIV antibodies, the use of acid-dissociated p24 assays enabled us to assign some additional infants to the HIV-infected cohort.

RESULTS

Transmission could be documented in 27% of infants born to HIV-infected women. Excess early deaths occurred in infants of HIV-infected women in Port-au-Prince with 60% of infected infants dead by 6 months of age. This is a more accelerated mortality than that in a group of 42 HIV-infected infants born of Haitian mothers living in Miami where 10% were dead at 6 months. Clinically, in 6 of 19 deaths in HIV-infected children in Haiti, failure to thrive and gastroenteritis lead to a systemic infection manifested as meningitis, sepsis or pneumonia as the immediate cause of death.

CONCLUSIONS

Early mortality attributable to perinatally acquired AIDS was identified in Haiti. The comparison of data from Miami and Port-au-Prince suggests that environmental exposures in developing countries may be more operative in this early mortality than viral strain or maternal host factors, both of which might be expected to be similar between the two groups of Haitian ethnicity.

The role of betamethasone in the treatment of acute exudative pharyngitis

OBJECTIVE

To compare betamethasone with placebo as an adjuvant to antibiotic therapy in the treatment of acute exudative pharyngitis.

METHODS

The study was a randomized, doubled-blind, placebo-controlled, single-center, parallel, outpatient clinical trial. After consent was obtained, each patient was asked to rate his or her pain on a 10-cm numbered visual analog scale (VAS; 0-10). All of the patients received injectable benzathine penicillin. If allergic to penicillin, they were started on a 10-day course of polyenteric-coated erythromycin (PCE). Each patient was randomized to receive either i.m. betamethasone or i.m. placebo. All patients were contacted by telephone at 24 and 48 hours by one of the study investigators and asked to rate their pain based on another VAS. If their pain was not resolved by 48 hours, they were called again daily between the third and seventh days after the initial visit to determine the time of pain resolution.

RESULTS

A total of 92 patients were enrolled in the study, with 46 randomized to receive placebo and 46 to receive betamethasone. Eight patients were excluded from the statistical analysis because of inability to obtain follow-up. Demographic comparison showed that gender distributions, ages, mean initial pain scores, mean times to the first and second follow-up calls, and treatment regimens were similar in the 2 groups. There were significantly better pain scores for the betamethasone group at first follow-up (p = 0.0005), at second follow-up (p = 0.004), and in number of hours until relief of pain (p = 0.004). When only those patients with a positive culture for a streptococcus species were analyzed, there also were significant reductions in pain score at the first (p = 0.006) and second (p = 0.02) follow-up visits.

CONCLUSION

Pain relief was greater and more rapid in patients treated with betamethasone as an adjuvant therapy in acute exudative pharyngitis.

On the singularity of the covariance matrix for estimates of multinomial proportions

It is well known that the covariance matrix for the multinomial distribution is singular and, therefore, does not have a unique inverse. If, however, any row and corresponding column are removed, the reduced matrix is nonsingular and the unique inverse has a closed form. We elucidate some of the properties of the multinomial covariance matrix and its reduced forms. We state and prove a theorem that gives insight into the singularity and its removal. Based on these results, we establish that the covariance matrix for the multinomial distribution is positive semidefinite and that the reduced matrix is positive definite. In addition, we show that the determinant of the reduced matrix is invariant to the particular row and column that are removed. Goodness-of-fit statistics, including Pearson's chi-square, and justification of the degrees of freedom follow from the multivariate central limit theorem once the singularity is removed.