[Wound treatment in diabetes patients and diabetic foot ulcers]. / Wundbehandlung bei Diabetes und diabetischem Fußulkus.

Diabetes mellitus (DM) is a paramount and rising medical challenge in both industrial and emerging nations. For Germany, 6.9 million out of 64.9 million insured persons in 2010 were reported to suffer from DM and approximately 5.8 million suffered from type 2 DM. The prevalence of diabetic foot ulcer (DFU) or diabetic foot syndrome (DFS) is 2-10% and the incidence is 2-6%. In addition, patients with DM present associated skin disorders with chronic wound healing, e.g., pyoderma gangrenosum or lecrobiosis lipoidica. Knowledge of the pathogenesis and skills for treatment of chronic wounds in diabetic patients are important for dermatologists. Patients with diabetes and wound healing disorders and accompanied unspecific skin disorders like eczema, cellulitis or contact dermatitis are often primarily or secondarily treated by dermatologists. In this article, practical hints for the treatment of DFS and other chronic wound in patients with DM are presented.

[Acute pulmonary embolism: still a diagnostic and therapeutic challenge?] / Akute Lungenembolie: immer noch eine diagnostische und therapeutische Herausforderung?

BACKGROUND: Acute pulmonary embolism (PE) is a cardiovascular emergency with high mortality in which a rapid diagnosis and the early initiation of therapy is vital. In the present study patients with acute PE hospitalized at the Clinic Lippe in Detmold were characterized and their prognosis examined. METHODS: In our department at the hospital Detmold, all patients with acute PE admitted in 2012 and 2013 were documented with respect to the severity of PE, predisposing risk factors and diagnostic and therapeutic steps. RESULTS: A total of 170 patients with acute PE were documented of which 80 patients (47 %) had low, 70 patients an intermediate (41 %) and 20 a high risk (12 %). The main diagnostic tool was thoracic computed tomography (82 %). All patients initially received unfractionated or low-molecular weight heparin; systemic intravenous fibrinolysis was carried out in 3 % of patients (intermediate risk n = 1, high risk n = 4). Nineteen percent (n = 13) of the patients at intermediate and 30 % (n = 6) of patients at high risk received local intrapulmonary fibrinolysis. Overall, the mortality rate in hospital was 10 % (low risk 2.5 %; intermediate risk 7 %; high risk 58 %). All 5 patients who received systemic emergency lysis died. One (5.3 %) of the 19 patients at intermediate risk, undergoing local intrapulmonary fibrinolysis, died. CONCLUSION: In acute PE a rapid diagnosis and the initiation of an adequate therapy remains a big challenge. Further studies are required to evaluate if aggressive treatment options might reduce mortality especially among patients at intermediate or high risk.

Left atrial thrombi and spontaneous echo contrast in patients with atrial fibrillation : Systematic analysis of a single-center experience.

BACKGROUND: Atrial fibrillation is associated with a high risk for thromboembolic events. Thrombi in the left atrial appendage and spontaneous echo contrast (SEC) correlate positively with this embolic risk. We studied the laboratory, echocardiographic, and epidemiologic parameters that could predict left atrial thrombi and the intensity of the SEC. PATIENTS AND METHODS: Between September 2013 and June 2015 we included 372 patients with atrial fibrillation before planned electrical cardioversion (transesophageal-guided strategy) in this study. After assessing the risk of stroke and bleeding (CHA2DS2-VASc and HAS-BLED scores), we measured the concentration of the D-dimer and B-type natriuretic peptide at the time of the transesophageal echocardiography as well as the left atrial volume and the ejection fraction during transthoracic echocardiography. RESULTS: The ejection fraction and the CHA2DS2-VASc score were identified as independent predictors of both left atrial thrombi and SEC, whereas the left atrial volume could only predict the intensity of SEC. In contrast to the results of other studies, the biomarkers in this study failed to predict the outcome. CONCLUSION: Only the echocardiographic and epidemiologic parameters were predictors of left atrial thrombi and SEC intensity, while the studied biomarkers had no predictive power. Using clinical data and transthoracic echocardiography, we can change the therapeutic strategy in high-risk patients.

[Treatment of coronary three-vessel disease in patients above 75 years]. / Therapie der koronaren Dreigefäßerkrankung bei Patienten über 75 Jahren.

BACKGROUND: Chronic ischemic heart disease take the first place in cause of death in Germany. The proportion of patients aged 75 years or older amounts more than 80 %. Due to their growing part of population the medical care of older patients becomes increasingly important. In this investigation patients aged ≥ 75 years with coronary three-vessel disease were characterized and various treatment strategies were compared. PATIENTS AND METHODS: This analysis was retrospective. The data of patients aged 75 years or older with three-vessel disease diagnosed by coronary angiography at the Klinikum Lippe Detmold between 2005 and 2007 were collected. Depending on the received therapy they were parted in three groups: optimal drug therapy (OMT), interventional - (PCI) and surgical revascularization (CABG). Patient characteristics as well as survival- and MACCE-rates during follow up were ascertained. Subgroup analyzes were performed for acute coronary syndrom (ACS) and stable coronary artery disease( CAD). RESULTS: The data of 434 patients with an average age of 79 years were documented. 139 (32.0 %) were assigned to the OMT- 189 (43.6 %) to the PCI- and 106 (24.4 %) to the CABG-group. Overall there was no significant difference between the three groups regarding mortality. In the subgroup of patients wit ACS (n = 180) mortality significantly increased in the OMT-group compared to the two invasive therapies (PCI (p = 0.029), CABG (p = 0.045)). The subgroup of patients with stable CAD showed no significant differences in mortality between the three types of therapy. CONCLUSIONS: Older patients benefit from an interventional or surgical revascularization in the context of ACS. In contrast, in elderly with stable CAD optimal medical therapy provides a reasonable alternative to invasive therapy without increase in mortality.

Predictors of Obesity in a Cohort of Children Enrolled in WIC as Infants and Retained to 3 Years of Age.

This longitudinal study of children enrolled as infants in the New York State (NYS) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) examined predictors of obesity (body mass index ≥ 95th percentile) at 3 years of age. NYS WIC administrative data which included information from parent interviews and measured heights and weights for children were used. All 50,589 children enrolled as infants in WIC between July to December 2008 and July to December 2009 and retained in WIC through age three were included. At 3 years of age, 15.1% of children were obese. Multiple logistic regression analysis showed that children of mothers who received the Full Breastfeeding Food Package when their infant was enrolled in WIC (adjusted OR = 0.52) and children with ≤2 h screen time daily at age 3 (adjusted OR = 0.88) were significantly less likely to be obese (p < 0.001) controlling for race/ethnicity, birth weight, and birthplace. In this cohort of NYS WIC participants, maternal receipt of the Full Breastfeeding Food Package (a surrogate measure of exclusive breastfeeding) is associated with lower levels of obesity in their children at age 3. The relationships between participation in WIC, exclusive breastfeeding, and obesity prevention merit further study.

[Renal artery stenosis: angioplasty or drug treatment?]. / Nierenarterienstenose: Intervention oder medikamentöse Behandlung?

BACKGROUND AND OBJECTIVE: Angioplasty in patients with renal artery stenosis aims at reducing blood pressure and at improving kidney function. Its efficacy has however been questioned by recent published data. It was the aim of this retrospective study to compare angioplasty with medical treatment in an unselected patient population. METHODS: Data on 109 patients were retrospectively analysed. This cohort included all those patients admitted to the Lippe-Detmold Hospital between 1992 and 2008 for renal artery stenosis. The data included blood pressure, creatinine-based calculated glomerular filtration rate (cGFR), any renal dialysis, cardiovascular risk factors, events and survival time after transluminal renal angioplasty or drug treatment, respectively. RESULTS: Patients who had undergone angioplasty were younger (p = 0.04), had less cardiovascular co-morbidity (p < 0.01), but a higher degree of stenosis (p < 0.01). After a median follow-up of 32.5 (angioplasty) and 36.0 months (drug treatment), respectively, a significant decrease of cGFR was recorded in drug treated patients (- 16.2 ml/min, 95 %, CI - 25.7 to - 6.7) but not in the angioplasty group (- 4.5 ml/min, 95 %, CI - 13.5 to 4.5). There were no other significant differences were not observed. CONCLUSION: Younger patients with a high degree of renal artery stenosis but without generalized atherosclerosis more frequently underwent angioplasty in clinical practice. The smaller post-angioplasty reduction in the loss of renal function in this group needs to be validated in a prospective, randomized study.

Haemodynamic, acid-base and blood volume changes during prolonged low pressure pneumoperitoneum in rabbits.

BACKGROUND: The anaesthetic management of small infants during advanced laparoscopic surgery can be complicated by the major pathophysiological effects of increased intra-abdominal pressure. In this study haemodynamic, acid-base and blood volume changes were investigated during pneumoperitoneum in a small animal model. METHODS: Ten fasted, anaesthetized, mechanically ventilated and multi-catheterized New Zealand rabbits were randomized to carbon dioxide pneumoperitoneum (PP, duration 210 min, pressure 8 mm Hg) or control group. Cardiac index was determined using trans-cardiopulmonary thermodilution and total blood volume was measured by thermal-dye dilution with indocyanine green using a fibreoptic monitor system. RESULTS: In PP cardiac index (CI), central venous oxygen saturation (Scv(O(2))), total blood volume (TBV) and base excess (BE) decreased significantly during the study whereas all variables remained constant in the control group. After release of PP the measured variables did not return to baseline within 30 min [PP, baseline vs study end: CI 108 (22) vs 85 (14) ml kg(-1) min(-1), Scv(O(2)) 81.4 (8.9) vs 56.7 (9.8)%, TBV 318 (69) vs 181 (54) ml, BE -1.9 (2.7) vs -8.7 (1.8) mmol litre(-1); P<0.01]. CONCLUSION: Our animal model suggests that a decrease in CI, metabolic acidosis and hypovolaemia could occur after prolonged low pressure pneumoperitoneum in small infants, which is possibly not detectable by the standard monitor setting. Therefore, the routine use of an extended monitoring including measurement of central venous oxygen saturation and acid-base parameters should be considered during and soon after operation, when pneumoperitoneum will last longer than 2 h.

Office-based methadone prescribing: acceptance by inner-city practitioners in New York.

In the US, methadone maintenance is restricted by federal and state regulations to large specialized clinics that serve fewer than 20% of the heroin-dependent population. In Europe, Canada, and Australia, primary health care providers already are utilized widely as methadone prescribers. In preparation for a limited study of office-based methadone treatment in New York City, 71 providers from 11 sites were surveyed about their willingness to prescribe methadone in their office-based practices. Of the 71, 85% had methadone-maintained patients who came to their practice for other care. One-third felt knowledgeable enough to prescribe methadone, and 66% said they would if given proper training and support (88% among AIDS care providers). Half expressed concern that they might be unable to meet the multiple needs of these patients. With additional training and ancillary support, the 47 providers willing to become methadone providers could serve, at 10-20 patients each, 470-940 patients, a population the size of 3-5 average methadone clinics.

Resolution of ST-segment elevation in acute myocardial infarction--early prognostic significance after thrombolytic therapy. Results from the COBALT trial.

In acute myocardial infarction, early identification of patients at a high mortality risk is important for planning further therapeutic strategies. Previous studies have demonstrated that the extent of early resolution of ST-segment elevation may represent a simple, quick and noninvasive assessment to identify high risk groups of patients. In a subgroup of the COBALT Study population (Continuous Infusion vs Double Bolus Administration of Alteplase), ST-segment elevation was measured before and 90 to 120 minutes after treatment with alteplase. The subgroup of n = 1,760 patients was not different from the total COBALT population of n = 7169 patients regarding most clinical parameters except Killip Class before treatment. However, the overall 30-day mortality differed significantly between the main study and the substudy (7.76% vs 3.52%; p < 0.001). Three groups of ST-segment resolution were defined: 1. complete resolution (resolution > or = 70%; 762 patients), 2. partial resolution (< 70% and > 30%; 491 patients), 3. no resolution (< 30%; 507 patients). Mortality rate at 30 days for complete, partial and no resolution of ST-segment elevation was 1.31%, 4.28% and 6.11%, respectively (p < 0.001). While this significant correlation between the extent of ST-segment resolution and mortality could be observed for inferior acute myocardial infarction, it could not be found in patients with anterior acute myocardial infarction. This in part may be due to a selection bias that leads to an extremely divergent mortality rate of anterior acute myocardial infarction in the main study and the substudy (10.1% vs 3.94%; p < 0.0001). Despite this limitation, resolution of ST-segment elevation in acute myocardial infarction after thrombolytic therapy allows to identify patients at a high mortality risk and may help to select patients for early invasive procedures such as PTCA. Patients with complete ST-segment resolution showed a particularly low mortality rate, irrespective of the alteplase regimen used (front-loaded alteplase vs double bolus alteplase).

Effectiveness of isoniazid chemoprophylaxis for HIV-infected drug users at high risk for active tuberculosis.

OBJECTIVE: To define the effectiveness of chemoprophylaxis, outside of a clinical trial setting, in preventing tuberculosis among tuberculin-reactive and anergic HIV-infected drug users at high risk of developing active tuberculosis. DESIGN: An observational cohort study. SETTING: Methadone maintenance treatment program with on-site primary care. PARTICIPANTS: Current or former drug users enrolled in methadone treatment. INTERVENTIONS: Annual skin testing for tuberculosis infection and anergy was performed, and eligible patients were offered daily isoniazid for 12 months and followed prospectively. MAIN OUTCOME MEASURE: The development of active tuberculosis. RESULTS: A total of 155 persons commenced chemoprophylaxis. Among tuberculin reactors, tuberculosis rates were 0.51 and 2.07/100 person-years in those completing 12 months versus those not taking prophylaxis [rate ratio 0.25, 95% confidence interval (CI) 0.06-1.01]. Among anergic individuals, comparable rates were 0 and 1.44/100 person-years. Lower tuberculosis rates among completers were not attributable to differences in immune status between the treated and untreated groups. CONCLUSION: The completion of isoniazid chemoprophylaxis was associated with a marked reduction in tuberculosis risk among tuberculin reactors and anergic persons in this high-risk population. These data support aggressive efforts to provide a complete course of preventative therapy to HIV-infected tuberculin reactors, and lend weight to the findings of others that isoniazid can reduce the rate of tuberculosis in high-risk anergic HIV-infected persons.

Three oral formulations of methadone. A clinical and pharmacodynamic comparison.

This study was done to determine whether there were any differences in subjective symptoms of opiate withdrawal or methadone pharmacodynamics among patients as they were switched between three different oral formulations of methadone. Patients enrolled in a three-way double-blind crossover trial of three methadone formulations. Subjective symptoms and pharmacodynamic measures were assessed throughout the study period. Eighteen patients were enrolled the study. No statistically significant differences in any of the pharmacodynamic parameters studied were found among the three methadone preparations. There was no significant difference among preparations in the rate and extent of rise and fall in plasma methadone levels during a 24-hour intensive sampling period. Subjective symptoms also did not correlate with methadone formulation. Intolerance to changes in methadone formulation, often observed clinically, do not appear to have a pharmacodynamic basis. Our findings support the notion that such change intolerance reflects factors other than the pharmacologic properties of the different formulations of methadone.

Methadone treatment protects against HIV infection: two decades of experience in the Bronx, New York City.

OBJECTIVE: We undertook a study of the role of methadone maintenance in protecting injecting drug users (IDUs) from human immunodeficiency virus (HIV) infection from the earliest days of the HIV epidemic in New York City to the present. The historical context of the epidemic in the Bronx is discussed. METHODS: For close to two decades, we have been tracking changes in injecting drug use and HIV infection levels in a Bronx cohort study of IDUs. An initial sample of 622 IDUs was recruited from a methadone treatment program in 1985, with historical data going back to 1978. Behavioral interviews and HIV testing were performed and methadone treatment program records (urine toxicology and methadone dose history) were reviewed. We examined both prevalent and incident HIV infections. The sample included African Americans (24.3%), Latinos (50.3%), and white non-Latinos (24.4%). The average methadone dose was 64 milligrams (mg) per day with an average time in treatment of five and a half years. RESULTS: We found a very low rate of incident infection of 1.7 per 100 person-years observation since 1986. Because of this low rate of infection, we were unable to determine the association between methadone treatment factors and HIV seroincidence. We found that our prevalence data on the 622 IDUs enrolled from 1985 to 1988 yielded strong findings on the role of methadone maintenance in a period when most infections occurred in this population. HIV seroprevalence was 42.9%. Logistic regression analysis revealed associations of methadone dose > or = 80 mg (adjusted odds ratio = 3.07/yr, 95% confidence interval (CI): 1.23-7.68) and last year entered methadone treatment (adjusted odds ratio = 1.22/yr, 95% CI: 1.06-1.41) to HIV infection, independent of year of last cocaine injection, needle sharing in shooting galleries, number of IDU sex partners, low income, and African American of Latino ethnicity. CONCLUSIONS: Properly dosed, long-term methadone treatment was found to be a central protective factor in preventing HIV infection from the earliest days of the epidemic in New York City. It is crucial to have high quality drug treatment programs in place before an epidemic draws our attention to the inadequacies through excess and unnecessary morbidity and mortality.

Staphylococcus aureus nasal colonization in HIV-seropositive and HIV-seronegative drug users.

Nasal colonization plays an important role in the pathogenesis of Staphylococcus aureus infections. To identify characteristics associated with colonization, we studied a cross-section of a well-described cohort of HIV-seropositive and -seronegative active and former drug users considered at risk for staphylococcal infections. Sixty percent of the 217 subjects were Hispanic, 36% were women, 25% actively used injection drugs, 23% actively used inhalational drugs, 23% received antibiotics, and 35% were HIV-seropositive. Forty-one percent of subjects had positive nasal cultures for S. aureus. The antibiotic susceptibility patterns were similar to the local hospital's outpatient isolates and no dominant strain was identified by arbitrarily primed polymerase chain reaction (AB-PCR). Variables significantly and independently associated with colonization included antibiotic use (odds ratio [OR] = 0.37; confidence interval [CI] = 0.18-0.77), active inhalational drug use within the HIV-seropositive population (OR = 2.36; CI = 1.10-5.10) and female gender (OR = 1.97; CI = 1.09-3.57). Characteristics not independently associated included injection drug use, HIV status, and CD4 count. The association with active inhalational drug use, a novel finding, may reflect alterations in the integrity of the nasal mucosa. The lack of association between HIV infection and S. aureus colonization, which is contrary to most previous studies, could be explained by our rigorous control for confounding variables or by a limited statistical power due to the sample sizes.

Measuring and comparing the attitudes and beliefs of staff working in New York methadone maintenance clinics.

Scales measuring commitment to abstinence-oriented policies, attitudes to drug addiction, and knowledge of methadone maintenance were refined and tested in a survey of staff working in 14 New York maintenance programs. Confirmatory factor analysis established the validity of a 9-item Abstinence Orientation Scale and a 6-item Disapproval of Drug Use Scale. Scores on the two scales and Knowledge scores were highly correlated. There were highly significant differences in the mean Abstinence Orientation scores of the administrative and better qualified clinical staff on the one hand and the less qualified staff on the other. Senior staff generally rejected abstinence-oriented policies while nurses and counselors tended to support them.

Needle exchange use among a cohort of injecting drug users.

OBJECTIVE: To study prospectively injection behavior of injecting drug users (IDU) who did and did not utilize a local needle exchange in the Bronx, New York City. DESIGN: Since 1985, IDU attending a methadone maintenance program have been enrolled in a prospective study of HIV-related risk behaviors. Since 1989, when a needle exchange opened near the methadone program, data have been collected from study participants regarding utilization of the exchange. PARTICIPANTS: Study participants (n = 904) who injected between 1985 and 1993. RESULTS: Of 904 IDU, 21.9% used the needle exchange. Male gender [adjusted odds ratio (AOR), 1.57], HIV seropositivity (AOR, 1.39) and younger age (AOR per 10 years of age, 1.66) were independently associated with needle exchange attendance. The percentage injecting declined each year, preceding the opening of the needle exchange and concurrent with its operation (from 64.6% in 1985 to 43.6% in 1993). Among the 329 participants who injected in the year before the exchange opened, 1988, 53 out of 124 (42.7%) needle exchange users and 168 out of 205 (81.9%) non-users reduced or stopped injecting by 1993 (P < 0.001). Exchange users shared needles less than non-users (P < 0.05 in 1993). HIV infection was unrelated to these reductions in injection. CONCLUSIONS: Methadone-treated IDU with access to a needle exchange reduced injecting and needle-sharing. This pattern of harm reduction, which began at least 4 years before the needle exchange opened, occurred in both those who did and did not utilize the needle exchange. Needle exchange, as a strategy to reduce injection-related harm, should not be viewed as discordant with methadone treatment.

Lack of association of induration size with HIV infection among drug users reacting to tuberculin.

Smaller tuberculin test induration sizes suggest eligibility for tuberculosis chemoprophylaxis in HIV-seropositive than in HIV-seronegative persons. To determine whether human immunodeficiency virus (HIV) infection is associated with induration size among tuberculin reactors, a cross-sectional study of HIV-seropositive and -seronegative drug users was performed. Twenty-four of 160 (15%) HIV-seropositive and 68 of 284 (24%) HIV-seronegative patients had reactions to purified protein derivative (PPD) of > or = 2 mm (OR = 0.56, 95% CI 0.32 to 0.96). However, the prevalence of tuberculin reactivity was equal among nonanergic subjects with and without HIV infection. Median induration size was similar among HIV-seropositive (20.5 mm) and -seronegative (17.5 mm) reactors. Thus, although HIV-seropositive patients were less likely, due to cutaneous anergy, to be PPD reactors, induration size was not associated with HIV infection among reactors. Although using a reduced cutpoint to determine suitability of chemoprophylaxis in HIV-seropositive persons may be prudent, the logical assumption that the loss of specificity this entails is accompanied by an increase in sensitivity for detecting Mycobacterium tuberculosis infection remains to be proved.

A prospective study of syphilis and HIV infection among injection drug users receiving methadone in the Bronx, NY.

OBJECTIVES: The purpose of this study was to assess the relationship between syphilis and human immunodeficiency virus (HIV) infection in injection drug users. METHODS: A 6-year prospective study of 790 injection drug users receiving methadone maintenance treatment in the Bronx, NY, was conducted. RESULTS: Sixteen percent (4/25) of HIV-seroconverting patients, 4.8% (16/335) of prevalent HIV-seropositive patients, and 3.5% (15/430) of persistently HIV-seronegative patients was diagnosed with syphilis. Incidence rates for early syphilis (cases per 1000 person-years) were 15.9 for HIV-seroconverting patients, 8.9 for prevalent HIV-seropositive patients, and 2.9 for persistently HIV-seronegative patients. Early syphilis incidence was higher among women than men (8.4 vs 3.2 cases per 1000 person-years). Independent risks for early syphilis included multiple sex partners, HIV seroconversion, paid sex, and young age. All HIV seroconverters with syphilis were female. CONCLUSIONS: Diagnosis of syphilis in drug-using women reflects high-risk sexual activity and is associated with acquiring HIV infection. Interventions to reduce the risk of sexually acquired infections are urgently needed among female drug users.

Heroin use during methadone maintenance treatment: the importance of methadone dose and cocaine use.

OBJECTIVES: The purpose of this study was to examine factors associated with heroin use during methadone maintenance treatment. METHODS: Logistic regression statistical models were used to examine data obtained in a cross-sectional sample of 652 methadone patients. RESULTS: Heroin use during the 3 months prior to interview was shown to be greatest among (1) patients maintained on methadone dosages of less than 70 mg/day (adjusted odds ratio [OR] = 2.1, 95% confidence interval [CI] = 1.3, 3.4) and (2) patients who used cocaine during treatment (adjusted OR = 5.9, 95% CI = 3.8, 9.1). These results were independent of treatment duration, treatment compliance, alcohol use, and socioeconomic factors. Cocaine users were more likely than nonusers of cocaine to use heroin at all methadone dosage levels. CONCLUSIONS: This study confirms and extends past research showing high-dose methadone maintenance to be important to heroin abstinence. Further investigation of the independent association between heroin use and cocaine use is needed.

Laboratory markers and the risk of developing HIV-1 disease among injecting drug users.

OBJECTIVE: To characterize the progression to HIV-1 disease among injecting drug users (IDU) according to laboratory markers. DESIGN: Prospective study of cohort of HIV-1-seroprevalent IDU, with case-comparison component. METHODS: Different laboratory markers were examined as predictors of progression to HIV-1-associated diseases including AIDS in a cohort of 318 HIV-1-infected IDU. The cohort was enrolled from a methadone treatment program in the Bronx, New York, USA. The independent utility of non-CD4 cell markers was evaluated after adjustment for the association of low CD4 lymphocyte count with AIDS risk. Clinical events in the natural history of HIV-1 were related to changes in levels of two variables related to duration of infection, CD4 lymphocyte count and serum beta 2-microglobulin (beta 2M) concentration. RESULTS: On univariate analysis, AIDS incidence measured from baseline increased with declining CD4 lymphocyte number and percentage, increasing serum beta 2M level, low platelet count, low leukocyte count and p24 antigenemia. Among HIV-1-related outcomes prior to any AIDS diagnosis, the relative risk of pyogenic bacterial infections conferred by these markers was similar to the relative risk of AIDS. For all HIV-1 outcomes, the elevated risk encountered at CD4 lymphocyte number < or = 200 x 10(6)/l was entirely due to the high risk at < or = 150 x 10(6)/l. On multivariate analysis, control for CD4 lymphocyte count eliminated the association of any other marker with increased AIDS hazard. HIV-1-related outcomes tended to occur in this order: multiple constitutional symptoms, oral candidiasis, pyogenic bacterial infections and AIDS. CONCLUSIONS: In HIV-1-infected IDU, several laboratory markers may predict AIDS when analyzed individually. These are not, however, independently related to increased AIDS risk after adjustment for low CD4 lymphocyte count. A CD4 count < or = 150 x 10(6)/l is more strongly related to immediate risk of adverse outcome than a count of 200 x 10(6)/l. A progressive series of clinical events is associated with markers of duration of HIV-1 infection, prior to and including AIDS diagnosis.