Arrangement and distribution of the arterial circle in brain of wild boar (sus scrofa scrofa) linnaeus (1758): qualitative and quantitative analysis

Thirteen brains of wild boar (Sus scrofa scrofa) were investigated with the purpose to discrebe the formation and the branchings of the brain arterial circle and basilar artery, from injetions of colored latex into the arteries of the base of the brain, and to establish the degree of correlativity between the rostro-caudal, latero-lateral lengths, weight, volume, carotid and basilar arteries diameter and the length of the basilar artery. To the anatomic study male and female heardswere used, from the slaughterhouse Pro Fauna licensed to abate and comercialize wild animal and under the Federal Inspection Service (SIF) control, situated in Iguape city, São Paulo. In all animal latex was injected after what the arteries of the base of the brain were dissected and observed. The obtained results indicated a domination of the internal carotid artery in the vascularization of the brain, and positive correlation between weight and volume in relation to the lenght of the brain in rostro-caudal and latero-lateral senses, in addition weight and volume have a perfect positive correlation, when one grows the other grows in the same rate.

HIV multidisciplinary teams work: support services improve access to and retention in HIV primary care.

The multidisciplinary team model of HIV care evolved out of necessity due to the diverse characteristics and needs of people living with HIV disease. Though it is now accepted as the international standard of care, it represents a significant departure from methods of care for other infectious diseases, and debate continues regarding the effectiveness of its interventions. The debate has been largely uninformed by data; for example, little is known about the relationship between ancillary support services and primary care outcomes. We hypothesized that support services increase access to and retention in HIV primary care in an inner city public hospital clinic. We conducted a retrospective analysis of clinical data sets on 2,647 patients at the CORE Center, Chicago from 1997-1998 to investigate the relationship between four support services-case management (CM), transportation (TRANS), mental health (MH) and chemical dependency (CD)-and access to and retention in HIV primary care. We found that patients who received each of these services were significantly more likely to receive any care, regular care and had more visits than patients with no service, and retention increased by 15-18%. Female gender, younger age, self-pay status and IDU predicted less regular care. Need for all services was substantial and significantly greater in women. Outcomes improved to the greatest extent among patients who needed and received each service. We conclude that support services significantly increased access to and retention in HIV primary care. Our findings validate the multidisciplinary team model of HIV care, and suggest that health services that are tailored to the express needs of patients lead to better care and improved health outcomes. Further testing of changes in health care delivery to meet the rapidly changing needs of people living with HIV disease and respond to the constantly changing practice of HIV medicine is urgently needed to maintain and extend the advances in HIV care outcomes of the past decade.

Management of the adverse effects of antiretroviral therapy and medication adherence.

A commonly cited cause of poor adherence to highly active antiretroviral therapy (HAART) is adverse drug reactions. Short-term adverse effects are potential threats to successful introduction and maintenance of HAART. The long-term toxicities of HAART are still emerging and being defined, as evidenced by the recently described metabolic disorders (i.e., the syndrome of maldistribution, hyperlipemia, glucose intolerance and insulin resistance). With 14 licensed agents in 2000, other agents in common use, and numerous combinations of >/=3 drugs, awareness and recognition of adverse effects are increasingly important for clinicians and patients. The common adverse drug reactions encountered with HAART, including new agents and their impact on patient adherence, are reviewed. Current strategies to anticipate and mitigate adverse effects are summarized.

Marked declines in human immunodeficiency virus-related mortality in Chicago in women, African Americans, Hispanics, young adults, and injection drug users, from 1995 through 1997.

BACKGROUND: Declines in human immunodeficiency virus (HIV)-related mortality between 1995 and 1996 were seen across the United States but were small to nonexistent among people in marginalized sectors who are most likely to contract HIV and die of its effects. No comprehensive analysis describing HIV-related mortality in 1997 was available. OBJECTIVE: To describe Chicago's HIV-related mortality trends up to and including 1997, with specific attention focused on marginalized populations. METHODS: An analysis of cross-sectional HIV-related mortality data with emphasis on the years 1995 through 1997 was conducted for Chicago, Ill. Numbers, proportions, and rates of declines in HIV-related deaths were examined for the city as a whole and also among those diagnosed at Cook County Hospital, as a proxy for people with very low socioeconomic status. RESULTS: Between 1995 and 1996 there was an overall decline of 19% in HIV-related mortality in Chicago but small or no declines among women, African Americans, Hispanics, injection drug users, and people aged 20 to 29 years and more than 50 years. Between 1995 and 1997 there was an overall decline of 61%. At that time the declines were spread more evenly across diverse groups. There were almost no significant differences between the declines for these groups at Cook County Hospital and in the rest of Chicago. CONCLUSIONS: The HIV-related mortality has fallen dramatically in Chicago since 1995, the year of its maximum. During 1997, declines were seen among all groups. Declines were also seen among the most disenfranchised of the city. Access to care and the new combination therapies are apparently sustaining life for many in Chicago.

Comparison of 21 vs. 25 mm gastrojejunostomy in the gastric bypass procedure--early results.

BACKGROUND: Many bariatric surgeons consider a small gastrojejunostomy stoma critical to the success of gastric bypass. METHODS: We retrospectively compared a 21 vs. 25 mm gastrojejunostomy in 50 patients undergoing gastric bypass for morbid obesity. RESULTS: 31 patients were constructed with a 21 mm EEA, group I, and 19 with a 25 mm, group II. Average percent of excess body weight lost was 61%, 65%, and 64% at 12, 15, and 18 months follow-up in the group I patients, vs. 61%, 67%, and 69% in the group B patients. Differences were not significant. Complaints of nausea, vomiting, and/or dysphagia were similar between the groups. CONCLUSION: The choice of a 21 or 25 mm gastrojejunostomy does not appear to alter the success of gastric bypass surgery and can be based upon surgeon preference.

Seizure after exercise in the heat: recognizing life-threatening hyponatremia.

A 20-year-old military recruit suffered a generalized tonic-clonic seizure following 9 hours of moderate activity in a hot, humid environment. He had drunk at least 5.8 L of plain water before the seizure, and laboratory studies revealed that his serum sodium concentration was 113 mmol/L. Overconsumption of fluids during exercise may precipitate acute hyponatremia, a potentially life-threatening medical condition. Prompt correction of serum sodium in acute exertional hyponatremia is important to reduce the risk of permanent neurologic sequelae or death. Recommendations for prevention include ingesting the correct amount of fluid for the activity (the most important method) and consuming adequate salt through diet or beverage.

A randomized trial of daily and thrice-weekly trimethoprim-sulfamethoxazole for the prevention of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected persons. Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA)

We enrolled 2,625 human immunodeficiency virus-infected patients into a randomized trial to assess the efficacy and tolerability of daily vs. thrice-weekly trimethoprim-sulfamethoxazole (160 mg/800 mg) for prophylaxis of Pneumocystis carinii pneumonia (PCP). The rate of PCP was 3.5 and 4.1 per 100 person-years in the daily and thrice-weekly groups, respectively, with a relative risk (RR) of 0.82 (95% confidence interval [CI], 0.61-1.09; P = .16) (RR of <1.0 favors daily trimethoprim-sulfamethoxazole). The RR for PCP determined by on-treatment analysis was 0.59 (P = .03). The RR for death was 0.91 (P = .12); for bacterial pneumonia, 0.82 (P = .06); and for combined PCP and bacterial pneumonia, 0.84 (P = .04). Discontinuation due to adverse events occurred more commonly in the daily trimethoprim-sulfamethoxazole group (RR, 2.14; 95% CI, 1.73-2.66; P < .001). Overall estimates for efficacy end points favored daily trimethoprim-sulfamethoxazole, although rates of intolerance were higher among patients receiving that dose. Daily trimethoprim-sulfamethoxazole may offer advantages as a first choice for PCP prophylaxis; thrice-weekly dosing is an appropriate option for patients intolerant of the daily dose.

Current antiretroviral therapy and its impact on human immunodeficiency virus-related wasting.

Recent improvements in the management of people living with human immunodeficiency virus (HIV) disease in the United States have led to remarkable reductions in HIV-related morbidity and mortality. The Centers for Disease Control and Prevention recently reported substantial reductions in acquired immunodeficiency syndrome (AIDS)-related opportunistic infections and conditions, including HIV-related wasting. These achievements followed the introduction of the new class of antiretroviral therapies, the aspartyl protease inhibitors, and their use in combination with nucleoside inhibitors in so-called highly active antiretroviral therapies. In an effort to provide guidance for clinicians in HIV care, the Office of AIDS Research, United States Department of Health and Human Services recently convened a panel of experts to set clinical practice guidelines for the use of antiretroviral therapy in adults and adolescents. This article summarizes the new standard of care for the use of HIV therapies. It also reviews recent data suggesting that combination therapy has altered the natural history of HIV infection and has reduced the incidence of HIV-related nutritional disturbances and wasting.

Acyclovir use and survival among human immunodeficiency virus-infected patients with CD4 cell counts of < 500/mm3. The Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA).

To examine the relationship between acyclovir use and survival in AIDS, we performed a retrospective analysis of data collected through an observational cohort of the 17-site Community Program for Clinical Research on AIDS (CPCRA), under the sponsorship of the National Institute of Allergy and Infectious Diseases. Data were analyzed regarding 2,368 patients with CD4+ lymphocyte counts of < 500/mm3, and 7,836 follow-up visits were conducted from September 1990 to July 1994. Factors associated with use of acyclovir were studied by stratified analysis of variance and Mantel-Haenzel chi 2 tests. The association between acyclovir and survival was studied with use of the proportional hazards regression model. Individuals reporting acyclovir use were more likely to be white, male, and homosexual; to have a history of herpes simplex and zoster; and to have lower CD4+ T cell counts than those who did not. After adjustments for differences in baseline factors, acyclovir use was not associated with prolonged survival.

A comparative trial of zidovudine administered every four versus every twelve hours for the treatment of advanced HIV disease.

Zidovudine is approved for administration in doses given every 4 hours. Less frequent dosing has been used in many clinical trials, but the toxicity and efficacy of such regimens have not been formally compared with the approved regimen. In this multicenter, randomized, double-blind, controlled trial, the safety, tolerance and efficacy of 600 mg of zidovudine given daily in two or six divided doses were compared. Three hundred and twenty patients with a CD4 lymphocyte count < 250 cells/mm3 (mean, 104 cells/mm3) or a prior AIDS-defining illness were treated with zidovudine 100 mg every 4 hours (regimen A) or 300 mg every 12 hours (regimen B). Eighty-eight patients (56%) and 94 patients (58%), assigned to regimens A and B, respectively, completed the planned 48 weeks of treatment. Serious anemia (hemoglobin < or = 7.5 g/dl) occurred in 13% and 7% of patients treated with regimens A and B, respectively (difference, 6%, 95% confidence interval [CI], 2, 12%; p = .13). The mean duration of treatment and the frequency of neutropenia and symptomatic complaints including nausea and headache were similar in the two treatment groups. The number of patients experiencing a new opportunistic infection (18% versus 20% for regimens A and B, respectively), and the number of deaths (five in each group) did not differ significantly between groups. The effect of treatment on CD4 lymphocyte counts and HIV p24 antigenemia also was similar for both regimens. Zidovudine given at the more convenient dose of 300 mg twice daily has similar safety, and tolerance and appears to have similar efficacy to the currently approved regimen. Use of this regimen should help simplify the treatment of HIV disease.

Cigarette smoking, bacterial pneumonia, and other clinical outcomes in HIV-1 infection. Terry Beirn Community Programs for Clinical Research on AIDS.

Cigarette smoking has been associated with impaired immune defenses and an increased risk of certain infectious and neoplastic diseases in HIV-1 seronegative populations. We examined the relationship between cigarette smoking and clinical outcome in a prospective cohort of 3221 HIV-1-seropositive men and women enrolled in the Terry Beirn Community Programs for Clinical Research on AIDS. Differences in clinical outcomes between never, former, and current cigarette smokers were assessed using proportional hazards regression analysis. After adjustment for CD4+ cell count, prior disease progression, use of antiretroviral therapy, and other covariates, there was no difference between current smokers and never smokers in the overall risk of opportunistic diseases [relative hazard (RH) = 1.05; 95% confidence interval (CI) 0.90-1.23; p = 0.52] or death (RH = 1.00; 95% CI 0.86-1.18; p = 0.97). However, current smokers were more likely than never smokers to develop bacterial pneumonia (RH = 1.57; 95% CI 1.14-2.15; p = 0.006), oral candidiasis (RH = 1.37; 95% CI 1.16-1.62; p = 0.0002), and AIDS dementia complex (RH = 1.80; 95% CI 1.11-2.90; p = 0.02). In addition, current smokers were less likely to develop Kaposi's sarcoma (RH = 0.58; 95% CI 0.39-0.88; p = 0.01) and several other non-respiratory tract diseases. If confirmed by other studies, these findings have important clinical implications.

CD4+ T lymphocyte counts and patterns of mortality among patients infected with human immunodeficiency virus who were enrolled in community programs for clinical research on AIDS.

CD4+ T lymphocyte measurements are used frequently in clinical practice and have important prognostic implications. In this study, we describe mortality patterns for 5,204 human immunodeficiency virus (HIV)-infected patients classified in different CD4+ cell strata; patients with and patients without a history of disease progression were included. Patients were enrolled in studies sponsored by the Terry Beirn Community Programs for Clinical Research on AIDS of the National Institute of Allergy and Infectious Diseases between September 1990 and December 1993. Over a median follow-up period of 23.6 months, 1,703 of the 5,204 patients died. For those with CD4+ cell counts (/mm3) of < 25, 25-49, 50-99, 100-199, and 200-499, the cumulative mortality rates after 24 months were 72%, 58%, 47%, 27%, and 10%, respectively. The median survival time was 15 months for those with CD4+ cell counts of < 25 cells/mm3; 21 months for those with CD4+ cell counts of 25-49 cells/mm3; and 40 months for patients with CD4+ cell counts of 100-199/mm3. In each CD4+ cell stratum, mortality rates were higher for those with a history of disease progression at entry into the study; across all CD4+ cell strata, mortality was 60% greater (relative risk = 1.6; 95% confidence interval = 1.5-1.8). These data should be useful in planning clinical trials, and they have implications in terms of the frequency with which CD4+ cell counts should be measured to monitor the progression of HIV infection.

Quality measures in health care.

This article discusses measurement of quality in health care. The authors attempt to answer the following questions: why measure quality, and what will quality measurement do? The current quality measurement system is described including definitions of the measurable aspects of health care and current measurement tools. Finally, suggested benchmarks for various health care measurements are included.

Human immunodeficiency virus and hepatitis B virus seroprevalence in an urban trauma population.

OBJECTIVE: To determine the seroprevalence of the human immunodeficiency virus (HIV) and the hepatitis B virus (HBV) in patients of an urban level I trauma center. DESIGN: Prospective, blinded point prevalence study of serum HIV and HBV antibody and antigen. SETTING: An urban level I trauma center that participates in a trauma system serving three million people. PATIENTS: The study included 994 (94.8%) of 1049 consecutive trauma service patients treated between June 6, 1988 and September 22, 1988. The patients were 82.2% male and 73.1% black, with a mean age of 28.8 +/- 12.3 years. Blunt trauma was seen in 65.4% of patients, 5.2% were in shock, and 96.2% survived their trauma. MAIN OUTCOME MEASURES: HIV and HBV seroprevalence, using both antibody and antigen testing. RESULTS: HIV infection was seen in 43 patients (4.3%); 41 (95.3%) were HIV Ab+ and two (4.7%) were HIV Ab-/HIV Ag+. Infection with the HBsAg was seen in 31 patients (3.1%). Infection with either virus was seen in 70 patients (7%); four patients (0.4%) were infectious for both viruses. Infection was related to age 20 to 49 years, i.v. drug use, a hepatitis or sexually transmitted disease history, prior HIV testing, shock, and death (p < 0.05). Penetrating trauma was not predictive of infection. In a logistic regression model, IV drug use was the single significant predictor of infection (p < 0.05). CONCLUSIONS: Young urban trauma patients, because of drug-related intentional violence, are 15.3 to 17.6 times more likely to be HIV infected and 3.9 to 7.9 times more likely to be infectious for HIV or HBV than the trauma population overall. The 12 to 21% infection rates in critically injured patients who require shock resuscitation and/or die reinforces the need for mandated universal precautions and for clear policies which govern the performance of procedures by physicians in training. Primary HIV infection in critically injured patients may worsen their outcome and may adversely affect the exposed health care worker. Emergency departments and trauma units should develop a referral system to HIV primary care services (HIV counselling and testing) for high risk patients and for adversely exposed health care workers.

Survival and disease progression according to gender of patients with HIV infection. The Terry Beirn Community Programs for Clinical Research on AIDS.

OBJECTIVE: To compare disease progression and mortality between women and men infected with human immunodeficiency virus (HIV). DESIGN: Multicenter cohort. SETTING: Seventeen community-based centers participating in the Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA). PATIENTS: A total of 768 women and 3779 men enrolled in one or more of 11 protocols between September 7, 1990, and September 30, 1993. MAIN OUTCOME MEASURES: Survival and opportunistic events. RESULTS: The median CD4+ cell count at enrollment into the cohort was 0.240 x 10(9)/L (240/microL) for women and 0.137 x 10(9)/L for men (P < .001). Compared with men, women were younger (36 vs 38 years), more likely to be African American or Hispanic (78% vs 44%), and more likely to have reported a history of injection drug use (49% vs 27%). Women had been followed up for a median of 14.5 months and men for 15.5 months. The adjusted relative risk (RR) for death among women compared with men was 1.33 (95% confidence interval [CI], 1.06 to 1.67; P = .01) and for disease progression (including death) was 0.97 (95% CI, 0.82 to 1.15; P = .72). Women were at increased risk for bacterial pneumonia (RR, 1.38; 95% CI, 1.05 to 1.92) and at reduced risk for the development of Kaposi's sarcoma (RR, 0.16; 95% CI, 0.04 to 0.65) and oral hairy leukoplakia (RR, 0.54; 95% CI, 0.31 to 0.94). The increased risk of death and bacterial pneumonia for women compared with men was primarily evident among those with a history of injection drug use (RR, 1.68 for death, 95% CI, 1.20 to 2.35, P = .003; RR, 1.53 for bacterial pneumonia, 95% CI, 1.03 to 2.29, P = .04). Among patients without a history of disease progression at entry, death was the first event reported for more women than men (27.5% vs 12.2%). CONCLUSIONS: Compared with men, HIV-infected women in the CPCRA were at increased risk of death but not disease progression. Risks of most incident opportunistic diseases were similar for women and men; however, women were at an increased risk of bacterial pneumonia. These findings may reflect differential access to health care and standard treatments or different socioeconomic status and social support for women compared with men.