Risk factors for mortality among hospitalized children with persistent diarrhoea in Pakistan

We evaluated factors associated with mortality among a cohort of malnourished children with persistent diarrhoea (PD) admitted for nutritional rehabilitation with a defined rice-lentil (Khitchri) and yoghurt diet. Of 302 children consecutively admitted with PD, 13 (4 per cent) died, mostly (62 per cent) within 72 h of admission. Univariate analysis of risk factors at admission associated with mortality indicated significantly increased risk of death with severe stunting [relative risk (RR) 3.1, 95 per cent confidence interval (CI) 1.1-9.0], hypoalbuminaemia (RR 4.3, 95 per cent CI 1.5-12.3), stool frequency > 12/day (RR 6.0, 96 per cent CI 2.0-17.6), stool volume > 100 g/kg/day (RR 10.7, 95 per cent CI 3.0-37.6) and severe dehydration (RR 7.5, 95 per cent CI 2.6-21.8). Children who died also had comparatively shorter duration of diarrhoea at admission, and were also associated with higher rate of bacteremia at admission (Fisher's exact test P < 0.01). The logistic regression model evaluating multivariate risk of mortality identified weight-for-age z-score and sepsis as significant risk factors. Our data suggest that severe malnutrition and sepsis are associated with significantly increased risk of mortality in children with PD. Stringent screening for infections and recognition of subgroups with severe malnutrition and severe diarrhoea may improve screening and case management strategies for this disorder.     

Novel methods for molecular dynamics simulations

HYPOTHESIS: Monovalent measles vaccine can be administered to children 6 to 11 months of age during an outbreak. Efficacy and effectiveness of this control measure still have to be assessed. METHODS: During and outbreak of measles, monovalent measles vaccine was administered as part of outbreak control to children aged 6 to 11 months. Active surveillance was used to detect cases of measles occurring during the following month. Children who did not develop measles were tested for measles antibody before their revaccination at 15 months of age. RESULTS: Of 81 children 6 to 11 months of age, 56 were vaccinated and two received immunoglobulins; the latter were excluded from the analysis. Measles occurred in 15 of the 79 children during and after the vaccination campaign, for an overall attack rate of 19%. The attack rate among unvaccinated children was 39% (9 of 23), compared with 11% (6 of 56) among those vaccinated (relative risk = 3.6, 95% confidence interval [CI] = 1.5 to 9.1). All of those who sustained measles in the vaccinated group developed the disease within 10 days after vaccination. The overall vaccine effectiveness was 73% (95% CI = 32% to 89%) when children were classified as vaccinated as soon as they were given measles vaccine. It rose to 96% (95% CI = 72% to 99%) when children were considered vaccinated 1 week postimmunization. Nineteen infants who were vaccinated and who did not develop measles during the outbreak were tested for measles antibody status at 15 months of age before revaccination. All had plaque reduction neutralizing antibody titers greater than 120. CONCLUSION: This study confirms that measles vaccination of infants aged 6 to 11 months is an effective intervention measure during measles outbreaks.     

The prevalence of non-insulin-dependent diabetes mellitus and the associated risk factors in a population of Mexico, D. F

Non-insulin-dependent diabetes mellitus (NIDDM) is a chronic disabling disease, that shortens length of life and implies a high burden for a community. Its prevalence goes from 0 per cent in Papua, New Guinea to 34 per cent in Pima Indians. There are very few prevalence studies in Mexico, and the strength of association of the known risk factors with the occurrence of the disease is not established. A prevalence cross sectional study was carried out with users of a first level medical care unit, with a meter measure of capillary glucose levels. Those with a previous diagnosis of diabetes or whose capillary glucose level were 200 mg or over were considered diabetics. Hyperglycemia was when the levels were recorded between 121 and 199 mg. The crude prevalence of NIDDM was 5.6 per cent (CI 95% 4.5-6.8), With almost no sex difference. Hyperglycemia prevalence was 2.9 per cent (CI 95% 2.0-3.7). Age was the main risk factor for the development of NIDDM. Those between 40 and 59 years showed a high risk (OR 10.8; CI 95% 5.4-22.0; p < 0.0001), and it was greater for the 60 years or elder (OR 20.6; CI 95% 9.8-44.1; p < 0.0001). Weight was also an important risk factor, with a 2.7 fold greater risk for obese persons (CI 95% 1.6-4.6; p < 0.0001). Other, risk factors were familiar history of diabetes (OR 1.5; CI 95% 0.9-2.3; p = 0.096), and overcrowding (OR 1.9; CI 95% 1.0-3.4; p = 0.03). In order to analyze independently each variable, a logistic regression model was applied, and a similar strength of association was observed for the crude model, but for obesity whose effect was modified by age. When only new cases were analyzed in the former model, the association with obesity was maintained. There is a need to develop prevalence studies of NIDDM in Mexico and to measure the strength of association with the known and the not jet well known risk factors of this disease in order to establish health policies according to the Mexican reality.     

Measles outbreaks in the Bern canton

Currently, overall vaccination coverage against measles among infants ranges between 77% and 89% in Switzerland. Experience in other countries has shown that this level of vaccination is not sufficient to prevent measles outbreaks, especially among schoolchildren. During 1992 surveillance for measles outbreaks in closed populations was conducted in the Canton of Berne. Outbreaks were investigated for vaccine efficacy. Two measles outbreaks in schoolchildren were observed during the study period. In 2 Bernese suburban schools 6 measles cases in children (median age 12.5 years) occurred over a period of 37 days. One of the cases had been vaccinated. Vaccination rate in the healthy control children was 89.7%. Estimated vaccine efficacy was 97.7% (95% confidence interval [CI]: 68%, 99%). The second outbreak occurred in a rural region and comprised 21 measles cases (median age 7.5 years) within 43 days. 10 (47.6%) of the cases attended the same school. None of the cases had been vaccinated. Of the healthy control children 82.6% had received measles vaccine. Estimated vaccine efficacy was 100% (CI: 87%, 100%). These two measles outbreaks were due to failure to vaccinate rather than low vaccine efficacy. Surveillance for measles cases is currently not sufficient for the detection of measles outbreaks in our population. Laboratory confirmation of measles, especially in vaccinated persons, has become more important in a time of relatively low measles incidence.     

Impact of maternal and child health strategy on child survival in a rural community of Pondicherry

OBJECTIVE: To determine the impact of Maternal and Child Health (MCH) services on child survival in a socio-economically backward rural community. SETTING: Twelve villages in Pondicherry with a population of 16,803. DESIGN: Prospective study. SUBJECTS: A birth cohort of 356 live births (LB) born between January 1st and December 31st 1988. METHODS: The live births were followed-up from birth to five years age (1988-1993). The health care received by this cohort and the antenatal services received by the cohort mothers was reviewed. Outcome measures related to child survival were determined and their changing trend since 1967 was examined. RESULTS: Fifty-four per cent of the cohort children were from families below the poverty line. Antenatal registration and tetanus immunization coverage of the mothers of the cohort was 100%. Immunization coverage of the cohort children was more than 98% for BCG, DPT (three doses) and OPV (three doses) and 82% for measles. The infant mortality rate had reduced from 201/1000 LB in 1967 to 64/1000 LB (95% CI 58.9-68.1) in 1989. The child death rate decreased from 29.4/1000 children 1-4 years of age (1970) to 18/1000 (95% CI 13.9-22.1) in 1992. There were no deaths due to neonatal tetanus or measles. Neonatal mortality (35/1000 LB; 95% CI 29.9-40.1) was higher than the post-neonatal mortality (29/1000 LB; 95% CI 24.1-33.9). Fifty eight per cent of the neonatal deaths were due to non-infective causes like prematurity, birth asphyxia, birth injuries and congenital anomalies. Eighty per cent of post neonatal deaths were due to infections. Overall, the child survival index was high (91.27%; 95% CI 88.14-94.26). This was inspite of the low socio-economic background of the children's families. CONCLUSIONS: Good MCH services can substantially improve child survival inspite of prevailing low socio-economic situations. Inputs for neonatal care need to be strengthened to further enhance child survival.     

TNF-alpha receptor knockout mice are protected from the fibroproliferative effects of inhaled asbestos fibers

We performed a prospective observational cohort study of the epidemiology and etiology of nosocomial pneumonia in 358 medical ICU patients in two university-affiliated hospitals. Protected bronchoscopic techniques (protected specimen brush and bronchoalveolar lavage) were used for diagnosis to minimize misclassification. Risk factors for ventilator-associated pneumonia were identified using multiple logistic regression analysis. Twenty-eight cases of pneumonia occurred in 358 patients for a cumulative incidence of 7.8% and incidence rates of 12.5 cases per 1, 000 patient days and 20.5 cases per 1,000 ventilator days. Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, and Hemophilus species made up 65% of isolates from the lower respiratory tract, whereas only 12.5% of isolates were enteric gram-negative bacilli. Daily surveillance cultures of the nares, oropharynx, trachea, and stomach demonstrated that tracheal colonization preceded ventilator-associated pneumonia in 93.5%, whereas gastric colonization preceded tracheal colonization for only four of 31 (13%) eventual pathogens. By multiple logistic regression, independent risk factors for ventilator- associated pneumonia were admission serum albumin <= 2.2 g/dl (odds ratio [OR] 5.9; 95% confidence interval [CI] 2.0-17.6; p = 0.0013), maximum positive end-expiratory pressure >= 7.5 cm H2O (OR, 4.6; 95% CI, 1.4 to 15.1; p = 0.012), absence of antibiotic therapy (OR, 6.7; 95% CI, 1.8 to 25.3; p = 0.0054), colonization of the upper respiratory tract by respiratory gram-negative bacilli (OR, 3.4; 95% CI, 1.1 to 10.1; p = 0.028), pack-years of smoking (OR, 2.3 for 50 pack-years; 95% CI, 1. 2 to 4.2; p = 0.012), and duration of mechanical ventilation (OR, 3. 4 for 14 d; 95% CI, 1.5 to 7.8; p = 0.0044). Several of these risk factors for ventilator-associated pneumonia appear amenable to intervention.     

Risk factors for Clostridium difficile-associated diarrhoea in HIV-infected patients

OBJECTIVE: To identify risk factors associated with a first episode of Clostridium difficile-associated diarrhoea (CDAD) in patients with HIV infection. DESIGN: A case-control study. SETTING: University teaching hospital HIV inpatient unit. PATIENTS AND METHODS: Nineteen HIV-infected patients with CDAD, defined as diarrhoea with positive stool culture for Clostridium difficile (CD) and positive stool cytotoxin B assay, were compared with 38 randomly selected controls (HIV-infected patients hospitalized on the ward on the day the matched case was diagnosed). CD isolates were phenotyped by electrophoretic protein patterns. RESULTS: The incidence of CDAD among HIV-infected patients was 4.1/100 of patient-admissions. On univariate analysis, cases were more likely to have used clindamycin [11 out of 19 compared with four out of 38; odds ratio (OR) 19; 95% confidence interval (CI), 2-160; P = 0.0007], and pyrimethamine (14 out of 19 compared with 13 out of 38; OR, 4.8; 95% CI, 1.4-16, P = 0.02) in the month before diagnosis, and to have had cerebral toxoplasmosis (12 out of 19 compared with 13 out of 38; OR, 2.8; 95% CI, 0.9-8.6; P = 0.09). There was also a significant increase of the risk of CDAD as duration of hospitalization in the ward increased (chi 2 for trend, P = 0.007). Multivariate models associated two risk factors with CDAD: clindamycin use (OR, 42; 95% CI, 2-813; P = 0.01), and prolonged hospitalization in the ward (OR, 3.6 per week in the ward; 95% CI, 1-13, P = 0.048). Of 18 available CD isolates, 15 (83%) had identical electrophoretic protein pattern. CONCLUSIONS: Clindamycin use and prolonged hospitalization in the ward were the main risk factors associated with CDAD in this study. These observations, together with the occurrence of one major phenotype of CD, suggest nosocomial transmission of CD in the ward.     

Identification of a CA/TG repeat polymorphism proximal to the human DLX3 gene

The objective of the present study was to evaluate the effectiveness of BCG vaccination against tuberculosis (TB). TB cases occurring before 1 January 1995 among the birth cohorts 1980-1986 were identified from the Central TB Registry in Amman, Jordan and their BCG vaccination status determined. The proportion of vaccinated and unvaccinated children by age at vaccination and birth cohort was obtained from the Directorate of Chest Diseases based on the surveys conducted by the Directorate. A total of 429 cases of TB occurred among the above birth cohorts during the follow-up period. The overall BCG effectiveness against TB was 87 per cent (95 per cent CL 0.81-0.91). BCG was highly effective against pulmonary TB (85 per cent, 95 per cent CL 0.78-0.90) as well as extrapulmonary TB (95 per cent, 95 per cent CL 0.82-0.99). Our data suggest that BCG vaccination should continue to be considered as an important component of the strategy of TB prevention and call for improvement of coverage with this vaccine.     

Mortality among coal miners with pneumoconiosis in Poland

A mortality cohort study was carried out on 7,065 coal miners with pneumoconiosis first diagnosed during the years of 1970-85. The cohort was selected from among subjects entered into the National Register of Occupational Diseases and followed up through to the end of 1991. The general male population of Poland was considered as a reference group. The PYRS-3 programme was used to identify, by means of standardized mortality ratios (SMRs), total and selected cause-specific mortality. An analysis revealed significantly elevated total mortality (SMR = 105; 95% confidence interval (CI): 100-110) in the whole cohort of coal miners. The risk of selected cause-specific mortality was significantly enhanced due to diseases of the respiratory system among which pneumoconiosis predominated (SMR = 383; 95% CI: 345-424). While mortality from all diseases of the circulatory system (SmR = 89; CI: 82-96), arterial hypertension (SMR = 63; 95% CI: 38-98), cerebrovascular diseases (SMR = 79; 95% CI: 62-99), atherosclerosis (SMR = 79; 95% CI: 66-93), and injury in poisoning (SMR = 50; 95% CI: 38-64) was significantly lower. The risk of death from malignant neoplasm of lung in the whole study population as well as in individual groups and categories of coal miners with pneumoconiosis, which varied in the risk of pneumoconiosis and the level of exposure to ionizing radiation, was not increased.     

A case-control study of multiple myeloma and occupation

Lifetime job histories from a population-based, case-control study were analyzed to investigate the relationship between multiple myeloma and employment in various occupations and industries. Interviews were obtained from 89% (692) of eligible incident cases and 83% (1683) of eligible controls. An elevated risk was observed among persons ever employed as painters [odds ratio (OR) = 2.1, 95% confidence interval (CI) = 1.2-3.6], particularly for those employed for 10 or more years (OR = 4.1, 95% CI = 1.8-10.4). A small excess risk was observed among agricultural workers employed for 10 or more years (OR = 1.3, 95% CI = 1.0-2.2), with a higher relative risk observed among farm laborers (OR = 1.8, 95% CI = 1.0-4.0). Among agricultural workers who reported having been highly exposed to pesticides, the OR was 5.2 (95% CI = 1.6-21.1). Some evidence, based on smaller numbers, was also found to support an association with firefighting and employment in the petroleum- and coal-products manufacturing industries. Little evidence was found to support the previously noted association with wood exposure, and no evidence for an association with employment in the rubber or petroleum refining industries was found. This study lends further support to previously reported associations between multiple myeloma and employment among painters and agricultural workers.     

Situation of hypertension in some Bangkok slums

A cross-sectional epidemiologic survey was undertaken in slums in the catchment areas of two health centers in Bangkok. Two hundred and sixty representative households were randomly selected. All adults (993) aged 20 years and over who lived in the households were asked to participate. The results were, however, based on 809 subjects (89%) who responded and whose data were completed. It was found that prevalence of hypertension (blood pressure > or = 160/95 mmHg) was 14 per cent with a 95 per cent confidence interval of 11.8 and 16.4 per cent. Nearly half of the hypertensives were found to be mild cases (diastolic blood pressure = 95-105 mmHg). Less than half of the hypertensives were aware of their condition. Even a lower proportion was under treatment and had their blood pressure controlled. The results confirmed earlier studies that slum inhabitants seem to be at high risk of hypertension. Furthermore, the status of hypertensives in terms of awareness, treatment and control was unacceptably poor. This prompts a need to develop community programmes to cope with the problems.     

Splenic complications in chronic pancreatitis: prevalence and risk factors in a medical-surgical series of 500 patients

BACKGROUND: The prevalence, course, treatment, outcome and risk factors of splenic complications in chronic pancreatitis are poorly documented. METHODS: Patients with splenic complications in a medical-surgical series of 500 consecutive patients with proven chronic pancreatitis prospectively followed up for a mean of 7.0 years were compared with patients without splenic complications. RESULTS: Eleven men (2.2 per cent) with alcoholic chronic pancreatitis (median duration 2 (range 0-5) years) had a splenic complication: intrasplenic pseudocyst (n=5), subcapsular haematoma (n=2) or splenic rupture (n=4). All patients except one underwent splenectomy, five of whom also underwent distal pancreatectomy. There were no deaths. Patients with splenic complications had pancreatic tail necrosis (six of 11 versus 17.4 per cent; P=0.007), distal pseudocyst (six of 11 versus 11.7 per cent; P=0.0009) or splenic vein occlusion (seven of 11 versus 10.8 per cent; P< 0.0001) more frequently than those without. In the 22 patients with distal pseudocyst and splenic vein occlusion, the prevalence of splenic complications was 18 per cent (odds ratio 15.0 (95 per cent confidence interval 4.0-55.7). CONCLUSION: Splenic complications occur early in the course of chronic pancreatitis, are rare and are favoured by splenic vein occlusion and pseudocyst or necrosis of the pancreatic tail. Surgical treatment is usually required.     

The role of neuropaediatrician in the comprehensive management of children with cerebral palsy]

Nonmalignant respiratory disease (NMRD) mortality was examined among woodworkers participating in the American Cancer Society's CPS-II cohort study. During the 6-year prospective follow-up there were 97 NMRD death's among 11,541 men reporting employment in wood-related occupations and 1,338 NMRD deaths among 317,424 men reporting no exposure to wood dust or wood-related jobs. Relative risks, adjusted for age and smoking, were calculated using Poisson regression. A small excess of NMRD was observed among woodworkers. However, the relative risk was higher among woodworkers who did not report exposure to wood dust (RR = 1.52, 95% CI = 1.18-1.97) than those who did (RR = 1.27, 95% CI = 0.91-1.77), and no clear trend with duration of exposure was observed. An excess of NMRD was observed among woodworkers reporting exposure to asbestos (RR = 1.59, 95% CI = 0.85-2.96), as well as the small number of woodworkers reporting exposure to formaldehyde (RR = 1.95, 95% CI = 0.63-6.06), but men not reporting exposure to these substances also had an excess risk. Although limited by a short follow-up period and crude indicators of exposure, the strengths of this analysis were the ability to compare woodworkers to a similar, healthy population and to adjust for the effects of smoking. Cohort studies with better exposure information are needed to examine the role of occupational exposures among woodworkers in the etiology of respiratory disease.     

Clinical intestinal transplantation at the University of Pittsburgh: an update

In order to determine the outcome and associated chromosomal and structural anomalies in fetuses diagnosed in utero as having a congenital diaphragmatic hernia, we reviewed 48 consecutive cases referred to our regional Fetal Diagnostic Unit between 1988 and 1995. All babies were delivered in units with appropriate neonatal resuscitation facilities. Thirteen babies [34 per cent of those tested, confidence interval (CI) 19-49 per cent] had karyotypic abnormalities. Three had trisomies but the other nine had more complex karyotypic abnormalities including translocations, deletions, and marker chromosomes. Twenty-one fetuses (44 per cent, CI 30-58 per cent) had additional ultrasound abnormalities which affected the heart in ten cases (21 per cent). Overall, 13 babies survived (27 per cent, CI 14-40 per cent). In babies with normal chromosomes and no additional structural abnormalities the survival rate was 50 per cent (CI 25-75 per cent). Poor outcome was not predicted by early gestation at diagnosis, the hernial contents, or the presence of polyhydramnios. We conclude that parents should be counselled about prognosis with information derived from series of prenatally diagnosed diaphragmatic hernias. The investigations offered should include a detailed ultrasound examination, particularly of the heart, and karyotyping by fetal blood sampling.     

Cohort study of serum total cholesterol and in-hospital incidence of infectious diseases

A multiethnic cohort of adult members of the Kaiser Permanente Medical Care Program (55300 men and 65271 women) was followed for 15 years (1979-93) to assess the association between total cholesterol and risk of infections (other than respiratory and HIV) diagnosed in the in-patient setting. Using multivariate Cox regression, total cholesterol was inversely and significantly related to urinary tract, venereal, musculo-skeletal, and all infections among men; and to urinary tract, all genito-urinary, septicaemia or bacteraemia, miscellaneous viral site unspecified, and all infections among women. The reduction of risk of all infections associated with a 1 S.D. increase in total cholesterol was 8% in both men (95% CI, 4-12 %) and women (95% CI, 5-11%). For urinary tract infections among men, as for septicaemia or bacteraemia and nervous system infections among women, the risk relation was restricted to persons aged 55-89 years. Nervous system infections were positively related to total cholesterol among women aged 25-54. In both genders, the significant inverse association with all infections persisted after excluding the first 5 years of follow-up. Collectively, these data are suggestive of an inverse association, although not entirely consistent, between total cholesterol and incidence of infections either requiring hospitalization or acquired in the hospital. Further research is needed to elucidate whether these associations are biologically plausible or represent uncontrolled confounding by unmeasured risk factors.     

Partial agonists and full antagonists at the human and murine bradykinin B1 receptors

OBJECTIVE: To examine the incidence of first diagnosis of invasive squamous cell carcinoma (SCC) of the skin over time. DESIGN: Retrospective, population-based incidence study. SETTING: Enumerated, geographically isolated, semiurban population served by the Mayo Clinic and its affiliated hospitals and the Olmsted Medical Center, including its affiliated hospital in Rochester, Minn. METHODS: Using the Rochester Epidemiology Project databases that capture virtually all medical care provided to the residents of Rochester, we identified and reviewed records of all documented residents in whom histologically proven, invasive SCC of the skin was first diagnosed between 1984 and 1992. Age and sex stratum-specific rates were calculated, and age-adjusted rates observed over time for individuals aged 35 years or older were analyzed using Poisson regression. Adjusted rates were compared with the results of other studies. RESULTS: Review of 1630 records identified 511 incidence cases of SCC. Tumors located on the head and neck accounted for 66.4% of tumors in females and 72.9% in males. The annual age- and sex-specific incidence rates per 100,000 increased from 0 cases among males aged 0 to 14 years to 1286.0 cases among males aged 85 years or older. Over time, the annual age-adjusted incidence rates per 100,000 females rose from 46.5 (95% confidence interval [CI], 32.4-60.6) for the 1984 to 1986 period to 99.6 (95% CI, 80.4-118.7) for the 1990 to 1992 period and were 71.2 (95% CI, 61.7-80.8) overall. The corresponding rates for males were 125.9 (95% CI, 95.3-156.4), 191.0 (95% CI, 156.9-225.0), and 155.5 (95% CI, 137.0-174.0). The age- and sex-adjusted SCC incidence rates for the period from 1987 to 1989 and 1990 to 1992 exceeded those for the period from 1984 to 1986 (P = .03 and P < .001, respectively). Our age-adjusted rates for SCC were within the ranges seen in other white populations from temperate climates. CONCLUSION: The frequencies of first diagnosis of SCC are increasing at rates beyond those explainable by demographic shifts alone.     

Morphological changes of the corpus callosum in schizophrenia

Asthma and allergic disorders have been on the increase in recent decades, especially among children living in affluent countries; some aspects of the "Western" way of life may explain this trend. We evaluated the relation of aeroallergen skin test reactivity with socioeconomic status, number of siblings, and respiratory infections in early life. We examined a total of 2,226 schoolchildren, ages 7-11 years, in three areas of Lazio, Italy. Skin prick tests were performed to assess atopic status, and self-administered questionnaires were completed by the parents. The prevalence of prick test positivity was greater among children whose fathers were in the highest educational level than among those in the lowest [prevalence ratio (PR) = 1.58; 95% confidence interval (CI) = 1.21-2.06]. There was also a lower prevalence of atopy among larger sibships (PR = 0.38 for subjects with four or more siblings vs those without siblings; 95% CI = 0.14-0.99). A history of bronchitis or bronchiolitis before age 2 years was weakly associated with an increased risk of atopy, whereas a history of pertussis or pneumonia was not. Both the effect of father's education and the influence of larger sibship size remained when we adjusted for several potential confounding factors, including respiratory infections in early life. We infer that higher socioeconomic status and lower sibling number are determinants of atopy in this Italian population. Protection arising from early severe respiratory infections does not explain this association, although we cannot exclude a role for other viral infections.     

Incidence and risk factors of the association of AIDS and tuberculosis in Spain

BACKGROUND: Incidence of tuberculosis in persons coinfected with HIV is very high. The aim of this study was to determine the risk factors for tuberculosis in AIDS patients in Spain. PATIENTS AND METHODS: A study was carried into AIDS cases (1993 European AIDS case definition) over 12 years old, diagnosed in Spain in 1994. A comparison was run between cases with tuberculosis and the remaining reported AIDS cases on the register, by sex, age, transmission category and prison record. Multiple logistic regression was used to assess the independent effect of each variable, with the adjusted odds ratio (ORa) and their 95% confidence intervals. RESULTS: Annual incidence of AIDS and tuberculosis comorbidity was 8.9 per 100,000 inhabitants. Multivariate analysis revealed that tuberculosis in AIDS patients appeared with higher frequency in: males (ORa = 1.4; CI 95%, 1.3-1.6); the 13-29 age group (ORa = 1.3; CI 95%, 1.1-1.5) and the 30-39 year old group (ORa = 1.1; CI 95%, 1.0-1.3), injecting drug users (IDU) (ORa = 1.4; CI 95%, 1.2-1.6), and those patients with a prison record (ORa = 2.1; CI 95%, 1.9-2.4). CONCLUSIONS: In Spain, male AIDS patients, under age 40 years with a prison record and IDU have a higher risk of tuberculosis. Control measures for tuberculosis should therefore be intensified among these patients.     

Is access to medical care associated with receipt of HIV testing and counselling?

Lack of timely HIV testing leads to missed prevention opportunities and poor prevention counselling may be related to further disease spread. We examined the association of self-reported access to medical care with receiving HIV testing and preventive counselling services among a sample of patients with HIV disease prior to hospitalization. We conducted a cross-sectional interview of 217 Los Angeles patients hospitalized with HIV-related illness between 1992 and 1993 and abstracted clinical data from the medical record. Eighty-four per cent of patients received HIV testing prior to hospitalization, but only 33% received preventive counselling services. Only 48% of all patients rated outpatient medical care as somewhat or very easy to obtain. Controlling for severity of illness, better access to outpatient medical care (OR = 1.48; 95% CI = 1.02-2.15), having a regular source of care (OR = 3.40; 95% CI = 1.29-8.97) and non-homosexual mode of HIV transmission (OR = 0.31; 0.12-0.83) were associated with receiving HIV testing services prior to hospitalization. Having a regular source of care (OR = 3.55; 95% CI = 1.37-9.22), being VA (Veterans' Administration) insured (OR = 6.16; 1.46-26.05), older age (OR = 0.95; 95% CI = 0.90-0.99) and having a CD4 count between 101-200 (OR = 0.19; 95% CI = 0.06-0.63) were associated with receiving HIV counselling. Limited self-reported access to medical care is associated with fewer patients receiving HIV testing and counselling. Improving timeliness of HIV testing may require removing the barriers to medical care.     

Endoscopic palliation of malignant obstructive jaundice using resterilized accessories: an audit of success, complications, mortality and cost

OBJECTIVE: To assess the success, complications and cost of endoscopic endoprosthesis placement for palliation of obstructive jaundice caused by malignancy. METHODS: Four hundred and two consecutive patients with obstructive jaundice due to nonresectable malignancy undergoing endoscopic stenting were studied. Commercial or home-made 7F or 10F endoprostheses were placed using minor modifications of the standard technique. The accessories were sterilized and reused. RESULTS: Endoprosthesis placement was successful in 291 patients (72.4%, 95% CI 67.7-76.7)-241 in one attempt, 49 in two attempts, and one in three attempts. Fifty nine patients (14.6%, 95% CI 11.4-18.6) had procedure-related complications, including cholangitis (30), pancreatitis (15), perforation (3) and bleeding (11). The incidence of cholangitis was significantly higher in bifurcation blocks than in other lesions (17.6% vs 4.7%, p = 0.0005). The success rate did not differ between distal and proximal lesions (68.1% vs 72.9%). The procedural cost per patient could be reduced from Rs 14,850 to Rs 6565 by reusing accessories after sterilization, and using home-made stents. CONCLUSIONS: Endoscopic endoprosthesis placement is a safe and effective method for palliation of malignant obstructive jaundice. Preparation of indigenous stents and reuse of accessories can reduce the cost of the procedure by over 50%.