Declining HIV/AIDS mortality in New York City.

BACKGROUND: New York City has only 3% of the U.S. population but has reported nearly 16% of all AIDS cases. METHODS: This is an observational study using the New York City vital events and AIDS case surveillance registries to describe trends in HIV/AIDS mortality from 1983 through June 30, 1998. RESULTS: Annual HIV/AIDS deaths increased steadily until stabilizing at 7046 in 1995, declined 29% to 4998 in 1996, and declined 47% to 2625 in 1997. Comparing data from 1997 with those from 1995, declines occurred in all demographic groups and in all major HIV transmission categories: 74% in men who have sex with men, 68% in injecting drug users, and 64% in heterosexuals. In the first 6 months of 1998, declines were smaller than they had been in previous 6-month intervals in all demographic groups except Hispanic males and those between 35 and 44 years of age. From 1995 to the first 6 months of 1998, the number of people living with AIDS in New York City increased 22% (from 32,692 to 39,976). CONCLUSIONS: The precipitous 63% decline in HIV/AIDS deaths from 1995 to 1997 occurred at the same time that more effective antiretroviral therapies became widely available. The slowing in the mortality decline observed in 1998, however, suggests that although these new therapies may have a profound effect at the population level, deaths due to AIDS will continue.

Effect of HIV/AIDS versus other causes of death on premature mortality in New York City, 1983-1994.

This study examined years of potential life lost (YPLL) before age 65 years to assess the relative impact of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) versus other leading causes of death on premature mortality in New York City, New York, between 1983 and 1994. Most causes of death showed substantial year-to-year variation in YPLL, with the exception of HIV/AIDS. The YPLL attributed to HIV/AIDS increased monotonically from 11,866 in 1983 to 167,317 in 1994, a nearly 15-fold increase. The rank order of the relative contribution of HIV/AIDS to total YPLL changed from the eighth leading cause of death to the leading cause. YPLL from heart disease, which ranked second in 1983, declined to fourth in 1994, homicide was unchanged, and chronic liver disease declined from fifth to ninth rank. The annual YPLL attributed to malignant neoplasms was similar to that for heart disease, but peaked in 1984, and the reduction over the subsequent decade was about 13%. Total YPLL was 78% greater among males than among females in 1983 and was nearly twice as high in 1994. Premature mortality decreased steadily for non-Hispanic whites, from 150,967 to 135,027 years for the years 1983-1994, while increasing 20% among blacks (from 179,176 to 215,826 years) and 48% among Hispanics (from 89,869 to 132,869 years). Among blacks and Hispanics, homicide contributed more years of YPLL than did either heart disease or malignant neoplasms in every year of observation. The HIV/AIDS epidemic and mortality associated with violence have become important public health challenges to the health and well-being of New Yorkers.

Accuracy or bias in nurses' ratings of patient compliance: a comparison of treatment modality.

OBJECTIVE: The study examined the accuracy of nurses' assessments of patient compliance and identified factors influencing these assessments, including possible biases. DESIGN: Nurses' assessments of compliance, lab serum levels of dietary compliance, and interdialytic weight gain (IWG) were collected and compared to each other. End-stage renal disease (ESRD) patients on peritoneal dialysis (PD) and hemodialysis (HD) were compared on these measures and their compliance. SETTING: The study was conducted at the tertiary care university hospital at Stony Brook. PATIENTS: Data were collected for 62 ESRD patients (38 male, 24 female; mean age 54 years). The sample consisted of 26 HD and 36 PD patients. INTERVENTIONS: Nurses rated patients' compliance with fluid restrictions (HD patients only) and overall dietary compliance, as well as individual indicators of compliance including protein, potassium, and phosphorus compliance on a 7-point rating scale. Interdialytic weight gain, dietary (serum BUN and K levels), and medication compliance were recorded from charts for a 3-month period for each patient. MAIN OUTCOME MEASURES: The main outcome measures were the correlations between nurses' ratings of compliance and medical compliance data and the regression coefficients, which indicate the relative importance of each of the factors that nurses use to make their compliance ratings. RESULTS: Nurses' ratings for patients in both treatment modalities were highly correlated with the medical data for measures of fluid (r = 0.66, p < 0.001), potassium (r = 0.36, p < 0.01), and phosphorus (r = 0.36, p < 0.01). A regression analysis indicates that potassium (beta = 0.48, p < 0.001), phosphorus (beta = 0.19, p < 0.05), and protein (beta = 0.31, p < 0.01) all significantly contributed to nurses' assessments of patients' overall compliance. However, nurses' ratings of education levels for patients in both treatment modalities were not associated with phosphorus (r = 0.07, p < 0.61), protein (r = 0.18, p < 0.23), or potassium (r = 0.03, p < 0.85) measures. Finally, regressions revealed that nurses used personal knowledge of the patients when rating noncompliant patients (beta = 0.49, p < 0.05) but not when rating compliant patients (beta = 0.05, p < 0.75). CONCLUSIONS: Nurses rely heavily on medical records to rate patients' compliance and to make accurate assessments. Nurses also use several individual indicators (lab values and IWG) to rate overall dietary compliance, suggesting a thorough assessment. While assessments are not biased by personal factors such as nurses' perceptions of patients' education levels, nurses do rely on personal knowledge when rating noncompliant patients.

Evaluation of effects of altered gastric pH on absorption of dapsone in healthy volunteers.

A prospective, randomized, crossover study was performed with seven healthy volunteers to address the effect of increased gastric pH on dapsone absorption. Subjects were randomized to receive a single 100-mg dose of dapsone or a single 100-mg dose of dapsone in addition to 30 ml of a high potency antacid 1 h before dapsone administration and hourly thereafter for a total of 10 doses. Dapsone concentrations in serum were measured periodically for 48 h. No statistical differences between the two regimens were noted when mean dapsone maximal initial concentrations, times to peak, and areas under the curve were compared. These data suggest that an increase in gastric pH has little or no effect on the absorption of dapsone in healthy subjects.

Anaerobic infections. The basics for primary care physicians.

Anaerobic bacteria constitute a major portion of the normal human microflora, and some of them can cause disease in contiguous body parts, especially if there is a mucosal break. Most anaerobic infections are polymicrobial. Because anaerobes are difficult to culture, diagnosis is often made on the basis of clinical clues. Thus, knowledge of the common sites, predisposing conditions, and other representative features of anaerobic infections is critical. For anaerobic infections above the diaphragm, where Bacteroides fragilis is not a common isolate, high-dose penicillin G therapy is usually sufficient. Addition of clindamycin (Cleocin) or metronidazole (Flagyl, Metryl, Protostat) may be necessary for serious infections. Cefoxitin sodium (Mefoxin) or clindamycin is adequate for most anaerobic infections occurring outside the central nervous system. Metronidazole, chloramphenicol, imipenem, or beta-lactam antibiotics combined with beta-lactamase inhibitors may be preferable for serious infections. Appropriate coverage for aerobic bacteria must be included in the treatment regimen. Drainage of abscesses, decompression of infected spaces, debridement of necrotic tissue, and removal of foreign bodies are critical in management of many anaerobic infections.

High-titer positive nontreponemal tests with negative specific treponemal serology in patients with HIV infection and/or intravenous substance use.

Nontreponemal testing is a valuable tool in screening for syphilis. False-positive reactions are uncommon and are usually at a titer less than 1:8. We describe eight intravenous substance abusers and/or HIV-positive patients with high-titer (greater than or equal to 1:16) nontreponemal and negative treponemal serologies in whom the diagnosis of syphilis is unproven and possibly false.

Aseptic meningitis associated with naproxen.

A rare complication of nonsteroidal antiinflammatory drug (NSAID) use, particularly in patients with collagen vascular or autoimmune diseases, is aseptic meningitis. A healthy 21-year-old man receiving naproxen for muscle spasm was admitted with a chief complaint of severe headache. Approximately one week after beginning naproxen, the patient developed headache, fever (T 38.8 degrees C), shaking chills, and nuchal rigidity with occasional nausea and vomiting resulting in a 15-lb weight loss. Findings from a cerebrospinal fluid examination revealed polymorphonuclear pleocytosis and elevated protein, but no evidence of infection with bacteria, fungi, mycobacteria, or viral agents was noted. Within 36 hours of discontinuing naproxen, the meningitis-like symptoms markedly improved. Rechallenge with naproxen was not performed. In patients exhibiting meningitis-like symptoms, a thorough drug history, including that of recent or intermittent NSAID use, should be obtained.

Non-cytocidal natural variants of human immunodeficiency virus isolated from AIDS patients with neurological disorders.

To understand the mechanism of HIV-mediated neuropathology five viral isolates were obtained from four AIDS cases with central nervous system manifestations as the primary involvement. The isolates were identified as HIVs by antigenic cross-reactivity and nucleic acid hybridizations to HIV-specific antibodies and DNA probes. The replication and cytopathic properties of these isolates were studied and compared with lymphadenopathy-associated virus (HIVLAV). All isolates had replication competence equivalent to LAV, but four isolates did not kill T4 (CD-4) cells. This isolation of non-cytocidal natural variants of HIV raises the possibility that in some AIDS cases the neurological disorders might be due to HIV variants that are non-cytocidal to T4 cells. The results also indicate that virus replication and cytotoxicity are not always concordant functions in HIV.

In vitro susceptibility of Capnocytophaga species to antimicrobial agents.

A total of 33 clinical isolates of Capnocytophaga spp. were susceptible to 4-quinolone antimicrobial agents. The antipseudomonal penicillins tested were equally active against all isolates, as were cefuroxime, ceftriaxone, ceftizoxime, cefotaxime, latamoxef, and ceftazidime. Most isolates were resistant to trimethoprim, and some were resistant to aztreonam. Most regimens for the empirical treatment of septic episodes in immunocompromised patients are suitable for the treatment of Capnocytophaga spp. infections.

Amebic liver abscess: a therapeutic approach.

The clinical presentation of 48 patients with amebic liver abscess was no different than that reported in earlier studies. However, most patients were from countries endemic for parasitic disease. Failure to consider this diagnosis resulted in potentially avoidable surgery for six patients. Although metronidazole was successful primary therapy in 85% of 41 patients so treated, four of seven ruptured abscesses occurred in cases where metronidazole treatment failed. For assessment of factors that might predict metronidazole treatment failures, multiple parameters were analyzed. Of the factors evaluated, only timing of clinical response correlated with successful therapy. Ninety-four percent of metronidazole responders showed dramatic clinical improvement within 72 hours of initiation of therapy, whereas only 33% nonresponders had improved modestly during this time (P = .0014). Therefore, early diagnosis of amebic liver abscess in patients from endemic areas and treatment with metronidazole will result in successful therapy in 85% of cases. Surgical intervention or alternative medical therapy is indicated for those patients who do not respond after 72 hours of metronidazole therapy.

Antimicrobial susceptibility of Capnocytophaga.

Capnocytophaga (Bacteroides ochraceus, Center for Disease Control biogroup DF-1) is associated with sepsis in granulocytopenic patients and is isolated in large numbers from the affected periodontal pockets in patients with juvenile periodontosis. The minimal inhibitory concentrations (MICs) and minimal bactericidal concentrations (MBCs) of 17 antimicrobial agents for 13 strains of Capnocytophaga organisms were determined. In addition, the ratio of the MBC to the MIC for each antimicrobial agent was determined for each strain. At concentrations of 1 microgram/ml or less, penicillin, ampicillin, carbenicillin, erythromycin, and clindamycin killed 90% of the strains. At concentrations of 3.12 microgram/ml or less, tetracycline, metronidazole, cefoxitin, and chloramphenicol killed 90% of the strains. None of the aminoglycosides tested demonstrated antibacterial activity at 50 microgram/ml. Penicillin, ampicillin, carbenicillin, and cefoxitin exhibited MBC/MIC ratios of 4 or less with all strains. Erythromycin, tetracycline, and metronidazole exhibited MBC/MIC ratios of 4 or less for 12 of 13 strains. The MICs of cephalothin and cefazolin for 90% of the strains were 25 and 50 microgram/ml, respectively. The MBC/MIC ratios for these drugs were 4 or less for 12 of 13 and 7 of 13 strains, respectively. The MIC of cefamandole for 90% of the strains was 3.12 microgram/ml; however, only nine strains had an MBC/MIC ratio of 4 or less.

Capnocytophaga sepsis: a newly recognised clinical entity in granulocytopenic patients.

10 episodes of Capnocytophaga sepsis occurred in 6 patients with granulocytopenia, malignancy, and oral mucosal ulcerations. Capnyocytophaga is a newly described genus of gliding gram-negative bacilli which is physiologically and genetically identical to Bacteroides ochraceus and biogroup DF-1 of the United States Center for Disease Control and is commonly responsible for periodontal infections.

Pott's disease in heroin addicts.

Five cases of tuberculous vertebral osteomyelitis occurred in heroin addicts at St Luke's Hospital Center between 1955 and 1975. All patients were men, and four were between 19 and 33 years of age. In contrast with the indolent onset typical to pyogenic or fungal vertebral osteomyelitis in heroin addicts, patients with Pott's disease had an acute toxic reaction, with fever, back pain, weight loss, and night sweats. Neurologic abnormalities, uncommon with pyogenic or fungal vertebral infection, occurred in all patients with tuberculous involvement of the spine. Roentgenograms of the spine were atypical in four patients, including two with an "ivory vertebra." All patients had involvement of extravertebral sites, and one patient had infection with Mycobacterium tuberculosis and M avium.