Care of the trauma patient in the age of the human immunodeficiency virus

HIV-infected patients will be seen in emergency rooms and trauma centers because the number of infected patients is large and growing. Proper precautions by health care workers are effective in decreasing risk of transmission to a very low level, and, therefore, the fear of HIV should not dissuade the medical profession from giving these individuals proper care. Operative treatments should not be arbitrarily rejected simply because an HIV infection is detected because poor wound healing and infection appear to be much less of a risk than predicted. Unusual infections and intercurrent medical problems may require additional attentiveness to detect their existence and may require more complex treatment regimens to control.     

Fungal infection in the intensive care unit

Fungal infection in critically ill patients is an increasingly prevalent problem. Candida spp. cause the majority of these infections in ICU. They occur most commonly in patients with severe underlying illness, multiple courses of antibiotics and intravascular catheters. Clinical diagnosis is difficult due to nonspecific signs and the frequent occurrence of widespread superficial colonization with Candida spp. in ventilated patients. Most patients are diagnosed using inferential evidence of infection, such as persistent pyrexia despite antibiotics, raised serum C-reactive protein and the presence of individual risk factors. Amphotericin B and fluconazole are the most commonly used anti-fungals dependent on the identity of the fungus. Most of these infections are endogenous; however, a proportion may be caused via the hands of healthcare staff or contaminated medical equipment.     

Targeted gene correction: a new strategy for molecular medicine

OBJECTIVE: Microbiological testing evaluations of hygienic procedure properties using PALL BB22-15MS filters to prevent contamination of "single use" breathing circuits during anesthesia. DESIGN: Prospective study. SETTING: Two operating rooms in a University hospital. PATIENTS: One hundred and thirty eight patients underwent general anesthesia for urologic surgery procedures. Patients with positive tests for HIV, B and C hepatitis and those considered to be at risk for HIV infection were excluded. The study was divided into five phases on the basis of times of usage of the same circuit for an increasing number of patients: in phase I, microbiological tests were performed on 4 circuits used on 4 different patients; in phase II the same tests were performed on 2 circuits each used on two different groups of three patients; in phase III, a circuit was used on a group of 15 patients and another on a group of 16 patients and the results were analysed; in phase IV a circuit used in a group of 32 patients was evaluated and phase V involved the analysis of a circuit that was used in a group of 65 patients. INTERVENTIONS: A filter was left in place between the patient and the circuit's Y-piece during all phases of anesthesia. The level of microbial contamination of breathing circuits was analysed in order to evaluate the reliability of the procedure. RESULTS: All analysed circuits remained uncontaminated. Staphylococcus hominis was revealed in respiratory circuit no. 6 of phase II, probably as a consequence of secondary contamination. CONCLUSIONS: Our results confirm that this procedure with the routine placement of a PALL BB22-15MS filter at the circuit's Y-piece can provide an adequate level of protection against cross-infections during anesthesia. The hygienic protocol proposed may allow the change of the anesthetic breathing only once a month.     

General and oral manifestations of human immunodeficiency virus infection: a general overview with guidelines for infection control in the dental practice

The human immunodeficiency virus (HIV-1), responsible for the acquired immunodeficiency syndrome, has in the span of a decade become an epidemic of global proportions. Oral lesions, head and neck diseases are often the first manifestations of HIV-1 infection and AIDS. It is essential for all dentists to familiarize themselves with the oral manifestations of HIV-infection as well as the dental management of such manifestations. In addition to all health care, professionals should become acquainted with the "universal precautions" recommended by the Centers for Disease Control, in order to protect themselves, their staff, and their patients to minimize, if not totally eliminate, any risk of infectious disease transmission in the health care setting. This paper presents a general overview of the human immunodeficiency virus; oral manifestations of HIV-infection; "universal precautions" and guidelines for the control of infection in the dental practice.     

Infection control of hepatitis C in Dutch dialysis centres

BACKGROUND: In dialysis patients, blood transfusions and long-term dialysis are well-known risk factors for transmission of hepatitis C virus (HCV). Transmission of HCV by transfusions has become extremely rare since the introduction of antibody screening. However, nosocomial transmission of HCV within dialysis units still occurs. We performed a survey of current infection control measures against HCV in Dutch dialysis centres that had participated in a national HCV prevalence study. METHODS: All twenty-seven Dutch dialysis centres where HCV-positive patients had been identified (HCV prevalence 1-8%), participated. With the use of a questionnaire we evaluated screening procedures for resident patients and guest patients, routine hygienic measures in HCV-positive and -negative patients, and cleaning procedures of dialysis equipment. RESULTS: All centres except one screened new patients for HCV antibodies, but the frequency of periodic follow-up screening varied. Most centres requested HCV antibody screening of guest patients in advance, but in daily practice 55% of the centres dialysed guest patients even when HCV antibody status was not available. The majority of centres had not implemented special precautions for patients with unknown HCV antibody status. In most centres the use of protective glasses, masks and aprons depended on the HCV antibody status of the patients. Surprisingly, 85% of the centres allowed their nurses to operate dialysis machines with gloves possibly blood contaminated. All centres sterilized their machines at the end of the day, but only 77% sterilized their machines between all dialysis sessions. Traces of blood were removed with alcohol in 63% of the centres. CONCLUSION: Dutch dialysis centres have not yet implemented an optimal policy for prevention of HCV. Especially, operating dialysis machines with gloves might be a potential source for nosocomial transmission of HCV, not yet covered by the issued guidelines. Because dialysis patients probably have a prolonged serological window phase after a recent HCV infection, it does not suffice to implement a preventive strategy against nosocomial transmission based on the results of HCV antibody screening. Universal, rigorous implementation of adequate infection control measures irrespective of HCV antibody status should be the cornerstone for prevention of nosocomial transmission of HCV and other blood borne pathogens.     

End-stage renal disease in patients infected with human immunodeficiency virus: a retrospective review of 38 cases

A retrospective review was conducted to evaluate the influence of risk factors for human immunodeficiency virus (HIV) infection on the outcome of patients with end-stage renal disease (ESRD). The records of all patients seen at Howard University Hospital between February 1984 and July 1994 with a diagnosis of HIV infection were reviewed. Two hundred seventy-eight patients had a diagnosis of renal failure; 38 of these patients developed end-stage renal failure requiring dialysis. Risk factors for HIV infection in these patients were intravenous drug abuse, homosexual behavior, bisexual preference, and blood transfusion. None of these factors consistently influenced the survival of HIV-infected patients with ESRD.     

Behavioral determinants of occupational exposure to chemical agents.

Used the passive-active dimension of the job demand–control model (T. Theorell and R. A. Karasek, see record 83:28881) to examine the impact of behavioral factors on the exposure to and actual uptake of airborne lead in 2 lead exposed populations of male workers (18 from an electric accumulator factors and 18 from a lead smeltery) and to ascertain work-related determinants of hygienic behavior. Environmental exposure was assessed by measurement of the concentration of lead dust in ambient air at the workplace, and the intake of lead was assessed by measurement of the lead in blood level. In the work environment of Ss in active jobs, lower concentrations of lead in air were measures, but higher levels of lead in blood were observed in these workers. The opposite was true of workers in passive jobs. Differences in hygienic behavior (e.g., use of protective equipment) at work may explain these results. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Globoside expression within the human placenta

PURPOSE: To validate a computer-based area calculation method of quantification of rectal evacuation by using defecography videotapes and to use that method to compare evacuation in constipated patients with that in control subjects. MATERIALS AND METHODS: For validation of the method, simultaneous defecography and weight measurements were compared in 36 patients with constipation or incontinence. Evacuation was calculated as the rate of change of the contrast medium-covered rectal area (percentage per second) or of the evacuated amount of contrast medium (percentage per second [relative] and grams per second [absolute]). After method validation, from a series of 215 consecutive constipated patients, individuals with an isolated radiologic diagnosis of intussusception greater than 0.6 cm (n = 27), rectocele greater than 2 cm (n = 19), enterocele (n = 12), or paradoxic puborectal muscle contraction (n = 12) were selected. Rectal evacuation in these groups was compared with that in 30 control subjects. RESULTS: Rectal evacuation rates measured at defecography correlated well with weighed amounts of evacuated contrast medium during the initial and total evacuation periods in 21 patients without contrast medium leak (r = 0.92, P < .001). Constipation overall, a rectocele greater than 2 cm, or paradoxic puborectal muscle contraction were associated with impaired evacuation (P < .001). CONCLUSION: Area calculations of rectal evacuation reflect rectal emptying. A rectocele greater than 2 cm or a paradoxic puborectal muscle contraction may be associated with obstructed defecation.     

Biosafety in the clinical mycobacteriology laboratory

This article presents an expanded agent summary statement for laboratorians working with Mycobacterium tuberculosis. It focuses on reducing the serious risk of infection in clinical laboratories that process specimens from tuberculosis patients or that work with purified cultures of tubercle bacilli. Administrative and engineering controls, practices and procedures, and personal protective equipment are discussed. Guidelines for packaging specimens for transfer to another laboratory also are presented.     

The causal role for genital ulcer disease as a risk factor for transmission of human immunodeficiency virus. An application of the Bradford Hill criteria

BACKGROUND AND OBJECTIVES: Genital ulcer disease (GUD) has been reported to increase the risk for the acquisition of human immunodeficiency virus (HIV). Although many investigators have reported an increased risk for HIV infection in persons with concurrent or previous GUD, not all studies have been designed to determine whether GUD causes an increased risk for HIV infection or acts only as a risk marker for infection. The evidence from the literature is discussed, and the criteria for causal inference proposed by Sir Austin Bradford Hill are applied. GOAL: To evaluate the strength of the association between GUD and infection by HIV. STUDY DESIGN: Case-control, cross-sectional, and cohort studies that examined the association between HIV seroconversion and GUD were chosen from the literature. Twenty-seven epidemiologic studies were selected for analysis, many of which reported separate analyses of the association between HIV infection and herpes simplex virus infection, syphilis, or nonspecified GUD. The studies were analyzed to investigate the magnitude of association between GUD and HIV, and the evidence evaluated using Hill's criteria. RESULTS: Approximately two thirds of the analyses reported a statistically significant association between GUD and HIV infection. Fourteen studies reported 29 separate analyses using a case-control design, 18 of which reported a statistically significant association between GUD (GUD, herpes, and syphilis) and HIV infection, four analyses were of varying significance depending on the analytical technique used, and seven were nonsignificant. Thirteen studies reported 23 separate longitudinal analyses that used a nested case-control or cohort design: 11 reported a significant association, 11 had nonsignificant findings, and results of one study varied. No study reported a statistically significant negative association. When applying the literature to Hill's criteria, all nine criteria for causal inference were met, providing additional evidence that genital ulcers are associated with an increased risk for the development of HIV infection. CONCLUSIONS: The published evidence suggests that GUD increases the risk for HIV acquisition. Few studies, however, have examined carefully the temporal association between preexisting GUD and subsequent HIV acquisition. The analyses that simultaneously controlled for additional risks for HIV infection, such as lifetime sex partners or history of injection drug use, report a generally lower risk for HIV associated with GUD. It is likely that studies that adequately control for risk factors will find a lower risk associated with GUD than was reported in the literature earlier in the HIV epidemic. Future research needs and the problems associated with conducting these types of studies are discussed.     

Cervical cytology findings in women infected with the human immunodeficiency virus

It has been suggested that immunocompromised, HIV-infected patients are at risk of developing HPV infection and SIL. The well documented role of HPV and SIL in cervical carcinogenesis should lead to frequent, careful evaluation of HIV infected women. Forty-four cervical smears from 23 patients (20 HIV and 3 AIDS) were reviewed. While 11 of the 23 patients produced negative smears, 11 had abnormal cytological findings on at least one occasion. Sixteen smears (36 percent) from 10 patients (43%) showed evidence of HPV and/or SIL. Two smears (two patients) were assigned to the benign epithelial atypia category. (One of these showed keratosis which may indicate HPV infection.) Six smears (three patients) represented either a severe Trichomonas, fungal (Candida sp.), or Herpes infection. Three smears were deemed unsatisfactory for diagnosis due to severe acute inflammation or obscuring blood. Five biopsies were available. In four, histologic findings supported the original cytologic diagnosis. One patient with a negative smear had a biopsy showing condyloma. This study further supports an association of HPV and/or cervical dysplasia with HIV. Careful evaluation and follow-up of HIV-infected women is essential.     

Outbreak of adenovirus 35 pneumonia among adult residents and staff of a chronic care psychiatric facility

Outbreaks of acute respiratory disease caused by adenovirus are rarely documented in civilian populations, and adenovirus 35 is an uncommon serotype best recognized as a cause of serious disease in immunocompromised patients. An outbreak of adenovirus 35 pneumonia among residents and staff of a chronic care psychiatric facility was investigated. Fourteen (26%) of 53 residents and 4 (2%) of approximately 200 staff had radiographically confirmed pneumonia. Thirteen (93%) of 14 residents with pneumonia were hospitalized, 5 (36%) required mechanical ventilation, and 1 (7%) died. One staff member was hospitalized. Adenovirus infection was diagnosed in 17 (94%) persons with pneumonia by culture or serology and was confirmed as adenovirus 35 infection in 8 persons. Residents with pneumonia had resided at the facility longer than other residents. Chronic illness was not a risk factor for severe disease. Crowding and poor hygienic behaviors probably facilitated transmission among residents.     

Lidocaine does not depress reflex dilation of the pupil

INTRODUCTION: The goal of this study was to report and evaluate the place of external fixation in the treatment of trochanteric fractures in patients with high unacceptable operative risk to withstand conventional osteosynthesis. MATERIAL AND METHODS: From January 1990 to December 1991 (2 years period), 42 patients, 13 males and 29 female, mean age 84.1 years, suffering from trochanteric fracture and considered preoperatively as "poor medical status" were treated by external fixation and immediate mobilisation. The average operative time was 18 minutes and no blood transfusion was necessary per or post-operatively. The mean hospital stay was 19 days. RESULTS: All patients were followed up for 6 months post-operatively. During this time 8 patients (19 per cent) died due to medical problems unrelated to the fracture. All fractures united in an acceptable position at an average time of 10.4 weeks with no loss of reduction, no pin breakage, no deep infection. All hips were painless. Complications: proximal pin migration occurred in 3 patients (7 per cent) due to fracture impaction and superficial pin tract infection in 16 (38 per cent) with no further consequence. DISCUSSION: External fixation in trochanteric fractures has been applied since 1957 with good results. This series confirms the advantages of the method in patients with a high operative risk; these are short operative time, minimal blood loss, early mobilisation and acceptable morbidity and mortality rates, considering the old and senile age group with poor medical condition, not allowing conventional treatment. The minor complications such as superficial pin tract infection and proximal pin migration are easily controlled.     

Effect of spinal cord injury on the heart and cardiovascular fitness

The use of various FES protocols to encourage increases in physical activity and to augment physical fitness and reduce heart disease risk is a relatively new, but growing field of investigation. The evidence so far supports its use in improving potential health benefits for patients with SCI. Such benefits may include more efficient and safer cardiac function; greater stimulus for metabolic, cardiovascular, and pulmonary training adaptations; and greater stimulus for skeletal muscle training adaptations. In addition, the availability of relatively inexpensive commercial FES units to elicit muscular contractions, the ease of use of gel-less, reusable electrodes, and the increasing popularity of home and commercial upper body exercise equipment mean that such benefits are likely to be more accessible to the SCI population through increased convenience and decreased cost. The US Department of Health and Human Services has identified those with SCI as a "special population" whose health problems are accentuated, and so need to be specifically addressed. FES presents "a clear opportunity.... For health promotion and disease prevention efforts to improve the health prospects and functional independence of people with disabilities." As a corollary to this, the Centers for Disease Control and Prevention have recommended the development of techniques to prevent or ameliorate secondary disabilities in persons with a SCI. Patients with SCI have an increased susceptibility to cardiac morbidity and mortality in the acute and early stages of their injury. Most of these patients make an excellent adaptation except when confronted with infection or hypoxia. SCI by itself does not promote atherosclerosis; however, in association with multiple secondary conditions related to SCI, along with advancing age, patients with SCI are predisposed to relatively greater risk of heart disease. The epidemiologic significance of this is reflected in demographic studies that indicate an increasing number of SCI patients becoming aged. Currently 71,000 (40%) of the total 179,000 patients with SCI living in the United States are older than 40 years, and 45,000 have injuries sustained more than 20 years earlier. In addition, new injuries in the older population are increasing (currently 11% of all injuries), and some of these new patients with SCI already have pre-existing cardiac disease. Studies have demonstrated that improved lifestyle, physical activity, lipid management, and dietary restrictions can affect major risk factors for coronary artery disease. Therefore an aggressive cardiac prevention program is appropriate for patients with SCI as part of their rehabilitation. At a given submaximal workload, arm exercise is performed at a greater physiologic cost than is leg exercise. At maximal effort, however, physiologic responses are generally greater in leg exercise than arm exercise. Arm exercise is less efficient and less effective than lower body exercise in developing and maintaining both central and peripheral aspects of cardiovascular fitness. The situation is further compounded in SCI because of poor venous return as a result of lower-limb blood pooling, as a result of lack of sympathetic tone, and a diminished or absent venous "muscle pump" in the legs. This latter mechanism perhaps contributes the greatest diminution in the potential for aerobic performance in the SCI population. Obtaining a cardiopulmonary training effect in individuals with SCI is quite possible. Current studies indicate decreases in submaximal HR, respiratory quotient, minute ventilation, and oxygen uptake, with increases in maximal power output, oxygen uptake, minute ventilation, and lactic acid. Individuals with SCI have been shown to benefit from lower limb functional electrical stimulation (FES)-induced exercise. Studies have consistently reported increases in lower limb strength and cycle endurance performance with these protocols, as well as improvements in metabolic and     

Dyslipoproteinemia and diabetes

Dyslipidemia in patients with diabetes constitutes quantitative and qualitative abnormalities in all classes of lipoproteins and may be a significant contributor to the high risk of atherosclerosis in these patients. A step-care approach to therapy of diabetic dyslipidemia, including hygienic measures (diet and increased physical activity), hypoglycemic drugs, and lipid-lowering drugs, is recommended. The choice of lipid-lowering drugs depends on severity of hypertriglyceridemia. Statins and bile-acid-binding resins are the choice of therapy for diabetic dyslipidemia; however, for severely hypertriglyceridemic patients, fibric acid derivatives should be used. Nicotinic acid worsens hyperglycemia and, therefore, should be avoided. The value of estrogen replacement therapy in postmenopausal women with diabetes has not been established.     

Temperature- and capsaicin-sensitive nerve fibers in brown adipose tissue attenuate thermogenesis in the rat

Different variables influence the possibility that maternal viral infection may be transmitted to the fetus, although not all fetal infections result in fetal "illness" with consequent fetopathy. As concerns the fetus, prenatal diagnosis includes invasive techniques necessary for fetal tissue sampling. These techniques carry some risks. The fetal infectious risk, as determined by maternal clinico-serological profile and according to sonographic investigation, always should be weighed against the risks and benefits of invasive diagnostic procedures. The present study re-elaborates the criteria necessary for defining fetal risk as related to the maternal serological profile. In the 26 mothers with rubeola infection, the incidence of fetal mortality was 7.7%. Fetal prognosis worsens with the precocity of eruption. In these cases the esantema is the most reliable prognostic element as an indication to perform the invasive procedure. In the 15 patients with cytomegalovirus infection, no fetal or postnatal losses occurred. Morbidity occurred in 13.3% of cases, and the two ill fetuses were classified in the same risk group. In this group of patients, the maternal serological profile is a significant predictor of fetal morbidity.     

High-tech with the human touch: Using telehealth to reach America's children.

[Correction Notice: An erratum for this article was reported in Vol 31(2) of Professional Psychology: Research and Practice (see record 2007-17403-001). On page 4, the last sentence of text incorrectly reads, "For additional telehealth project, policy, legal, and funding information, visit OAT's web site at http://www.telehealth.hrsa.gov." The correct web site address is http://telehealth.hrsa.gov.] In the past decade, we have seen new telecommunication and information technologies used to provide health services, health professional and consumer education, and public health and administrative services. The application of these tools to health care, commonly referred to as telehealth, provides an unprecedented opportunity, as we embark on a new millennium, to take services to those in need-to "carry the water to the desert." Telehealth provides both a means to increase access, and to reengineer the processes of care, enhancing the equality and effectiveness of health services. This article illustrates how telehealth has helped children and youth in various health care settings. Many of these projects have been initiated with federal funds from OAT or other federal agencies. Some of the projects use technologies that require special phone lines and expensive equipment ranging from $15,000 to $50,000; others run over regular phone lines and use equipment costing between $500 to $1,000. Psychologists are involved in many of these projects as initiators of services, as members of multidisciplinary teams, and as researchers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Neurologic manifestations of HIV infection. Using imaging studies and antiviral therapy effectively

Patients with HIV infection are at risk for neurologic complications that can arise through various means. Nervous system disorders sometimes occur as a direct consequence of the HIV infection itself. Or, as immunodeficiency progresses, patients can become susceptible to numerous opportunistic infections and other conditions that have neurologic involvement. Even the antiviral drugs used to treat HIV infection can induce neurologic manifestations. Dr Rachlis discusses several of these manifestations and their management.     

Rhodococcus equi pneumonia in patients infected with the human immunodeficiency virus. Report of 2 cases and review of the literature

Rhodococcus equi is a cause of lung infection in immunosuppressed hosts. Since the start of the HIV epidemic, 76 cases of R. equi lung infection (MEDLINE 1985-96) affecting this population have been described. We report 2 additional cases and review the clinical data, radiological findings, treatment and outcome of these 78 patients. The mean age of these patients was 33 y; 69 were male. 71 met the criteria for AIDS (CDC 1993). Fever and cough were the presenting complaints in the majority of patients (84.3%). A single cavitary lung lesion in the upper lobes was the most common radiological finding (57.7%), although multiple cavitations, alveolar infiltrates and pleural effusion were also found. Treatment usually was based on synergistic antibiotic combinations for a long period of time determined on an individual basis. Surgery was performed only in 11 patients. Death attributable directly to R. equi infection is low (15.4%), however only half of the patients (53.8%) were completely cured. We conclude that R. equi infection should be strongly considered in any HIV patient who presents with cavitary lesions in the lung, especially if mycobacteria are not identified. Treatment must be based on synergistic antibiotic combinations, and surgery relegated to cases of chronic single cavitary lesions not responding to antibiotics.     

Gestational drive and the green-bearded placenta

A "green beard" refers to a gene, or group of genes, that is able to recognize itself in other individuals and direct benefits to these individuals. Green-beard effects have been dismissed as implausible by authors who have implicitly assumed sophisticated mechanisms of perception and complex behavioral responses. However, many simple mechanisms for genes to "recognize" themselves exist at the maternal-fetal interface of viviparous organisms. Homophilic cell adhesion molecules, for example, are able to interact with copies of themselves on other cells. Thus, the necessary components of a green-beard effect -- feature, recognition, and response -- can be different aspects of the phenotype of a single gene. Other green-beard effects could involve coalitions of genes at closely linked loci. In fact, any form of epistasis between a locus expressed in a mother and a closely linked locus expressed in the fetus has the property of "self-recognition." Green-beard effects have many formal similarities to systems of meiotic drive and, like them, can be a source of intragenomic conflict.