Accidental exposure of veterinary students to rabies

Accidental exposure to rabies occurred in more than 200 veterinary students at Texas A&M University from 1970 to 1977. Few of the animals to which the students were exposed had typical signs of rabies prior to the exposures. An accelerated preexposure rabies prophylaxis program coupled with retention of suspect tissues suitable for fluorescent antibody procedures has reduced the number of postexposure prophylaxis series.     

Accidental occupational exposure of intravenous nurses to human immunodeficiency virus. Anticipating the consequences

The relationship of parental history of high blood pressure (HBP) to blood pressure (BP) was estimated in three Japanese population samples, totalling 591 men and women aged 20-59 years, from the INTERSALT study. Parental history of HBP was defined as reported HBP by their father and/or mother. With adjustment for antihypertensive medication, body mass index, alcohol intake, and Na/K ratio in 24-h urine, for participants with a parental history of HBP compared to those without a history, BP was higher for three to four age-sex strata, both for systolic and diastolic pressure (SBP, DBP), by 3.3 to 6.8 and 2.7 to 5.5 mm Hg respectively, with four of these six positive associations statistically significant. This finding was stronger for persons aged 40-59 than for those aged 20-39. These data support the judgment that for persons with a parental history of HBP, BP is apt to increase more with age due to combined effects of genetic and environmental factors. Such people especially need to control their lifestyles carefully, including to maintain an optimal intake of salt (eg, <70 mmol/day) and a high potassium intake, to avoid high alcohol consumption, and keep weight moderate, for the prevention of hypertension.     

Cost-effectiveness of chemoprophylaxis after occupational exposure to HIV

OBJECTIVES: To assess the economic efficiency of recent US Public Health Service recommendations for chemoprophylaxis with a combination of antiretroviral drugs following high-risk occupational exposure to human immunodeficiency virus (HIV). To provide a framework for evaluating the relative effectiveness and costs associated with candidate postexposure prophylaxis (PEP) regimens. METHODS: Standard techniques of cost-effectiveness and cost-utility analysis were used. The analysis compares the costs and consequences of a hypothetical, voluntary combination-drug PEP program consisting of counseling for all HIV-exposed health care workers, followed by chemoprophylaxis for those who elect it vs an alternative in which PEP is not offered. A societal perspective was adopted and a 5% discount rate was used. Hospital costs of recommended treatment regimens (zidovudine alone or in combination with lamivudine and indinavir) were used, following the dosing schedules recommended by the US Public Health Service. Estimates of lifetime treatment costs for HIV and acquired immunodeficiency syndrome were obtained from the literature. Because the effectiveness of combination PEP has not been established, the effectiveness of zidovudine PEP was used in the base-case analyses. MAIN OUTCOME MEASURES: Net PEP program costs, number of HIV infections averted, cost per HIV infection averted, and cost-utility ratio (net cost per discounted quality-adjusted life-year saved) for zidovudine, lamivudine, and indinavir combination PEP. Lower bounds on the effectiveness required for combination regimens to be considered incrementally cost saving, relative to zidovudine PEP alone, were calculated. Multiple sensitivity and threshold analyses were performed to assess the impact of uncertainty in key parameters. RESULTS: Under base-case assumptions, the net cost of a combination PEP program for a hypothetical cohort of 10,000 HIV-exposed health care workers is about $4.8 million. Nearly 18 HIV infections are prevented. The net cost per averted infection is just less than $400,000, which exceeds estimated lifetime HIV and acquired immunodeficiency syndrome treatment costs. Although combination PEP is not cost saving, the cost-utility ratio (about $37,000 per quality-adjusted life-year in the base case) is within the range conventionally considered cost-effective, provided that chemoprophylaxis is delivered in accordance with Public Health Service guidelines. Small incremental improvements in the effectiveness of PEP are associated with large overall societal savings. CONCLUSIONS: Under most reasonable assumptions, chemoprophylaxis with zidovudine, lamivudine, and indinavir following moderate- to high-risk occupational exposures is cost-effective for society. If combination PEP is minimally more effective than zidovudine PEP, then the added expense of including lamivudine and indinavir in the drug regimen is clearly justified.     

Cost-effectiveness of post-exposure prophylaxis following sexual exposure to HIV

OBJECTIVES: To assess the cost-effectiveness, relative to other health-related interventions in the U.S., of post-exposure prophylaxis (PEP) following potential HIV exposure through sexual contact with a partner who may or may not be infected, and to compare the relative cost-effectiveness of dual- and triple-combination PEP. METHODS: Standard techniques of cost-utility analysis were used to assess the cost-effectiveness of PEP with a four-week regimen of zidovudine and lamivudine, or zidovudine, lamivudine, and indinavir. Due to a lack of empirical data on the effectiveness of PEP with combination drug regimens, the analysis assumed that combination PEP was no more effective than PEP with zidovudine alone. The main outcome variable is the cost per quality-adjusted life year (QALY) saved by the program. RESULTS: Providing PEP to a cohort of 10,000 patients who report receptive anal intercourse with a partner of unknown HIV status (who is assumed to be infected with probability equal to 0.18) would prevent about 20 infections, at an average net cost of about US$ 70,000 per infection averted. The cost-utility ratio, US$ 6316 per QALY saved, indicates that PEP is highly cost-effective in this instance. Moreover, triple-combination PEP would need to be about 9% more effective than dual-combination PEP for the addition of indinavir to the regimen to be considered cost-effective. Prophylaxis following receptive vaginal exposure is cost-effective only when it is nearly certain that the partner is infected; PEP for insertive anal and vaginal intercourse does not appear to be cost-effective. CONCLUSIONS: From a purely economic standpoint, PEP should be restricted to partners of infected persons (e.g., serodiscordant couples), to patients reporting unprotected receptive anal intercourse (including condom breakage), and possibly to cases where there is a substantial likelihood that the partner is infected. Providing PEP to all who request it does not appear to be an economically efficient use of limited HIV prevention and treatment resources.     

Occupational exposure to HIV: considerations for postexposure prophylaxis and prevention

HIV seroconversion as a result of an occupational exposure is a terrifying concern of healthcare workers who deliver care to patients in a variety of health care settings. In this article the most recent CDC guidelines for the management of HIV exposure and postexposure prophylaxis are reviewed. Prevention of bloodborne pathogen exposures, specifically through the selection of safety devices, is recognized as an important issue.     

Prophylaxis after occupational exposure to human immunodeficiency virus (HIV)

Reasons for seeking consultation among health care workers due to potential or supposed risk of HIV infection were analyzed. From August 1990 till July 1996 41 health care providers were consulted including: 22 nurses, 1 student of nursing college, 3 midwives, 4 laboratory workers and 7 physicians (surgeons and gynaecologist). Type of exposure to HIV and applying of safety precautions were evaluated in each case. In 10 cases the offer of postexposure prophylaxis with zidovudine was accepted (6 nurses, 1 student of nursing college, 3 surgeons). Exposure to HIV was described as: needlestick immediately after it was used in a HIV/AIDS patient, injury with a surgical needle while operating on an HIV infected blood. In the remaining cases the fear of HIV infection was due to work without protective gloves (nurses, laboratory workers), performing surgery on HIV (+) patient, (surgeons, nurses) or short-time contact of HIV infected blood with undamaged skin (nurses). Following conclusions can be drawn from our study: 1. Health care workers undertake safety precautions only when they are informed about HIV seropositivity of the patient. 2. Patients whose HIV serologic status is not known are considered not to create health risk for medical staff. 3. The level of knowledge of health care workers about risk of acquiring HIV infection, lack of risk and ways of diminishing the risk is poor. 4. None of followed health care workers was HIV-seropositive after occupational exposure to HIV.     

Occupational exposure to HIV: experience at a tertiary care center

We examined our hospital-based occupational health clinic's experience with combination antiretroviral therapy for postexposure prophylaxis for human immunodeficiency virus (HIV). Over a 12-month period, 68 workers started postexposure prophylaxis: 23 with zidovudine and lamivudine and 45 with zidovudine, lamivudine, and indinavir. Fifty-one (75%) of the 68 workers starting postexposure prophylaxis reported one or more side effects. Side effects were more common among those taking three drugs. Many workers failed to complete the recommended 28-day regimen because of the side effects of the various treatments. The estimated mean cost for evaluations, prophylaxis, and monitoring of exposed workers was $669 per reported exposure. In our experience, major challenges in carrying out the current HIV postexposure prophylaxis guidelines include expeditious source testing, improved staff education and prevention measures, and scrupulous monitoring of workers taking combination antiretroviral drugs for postexposure prophylaxis, with consideration of alternate regimens for intolerant workers.     

Accidental intra-arterial injection of ketamine

A case of accidental intra-arterial injection of ketamine is reported. Necrosis of the skin proximal to the site of injection and transient foot drop followed the injection.     

Accidental poisoning in young children

Cases of accidental childhood poisoning admitted to hospital were compared with community controls and hospital controls matched for age and sex. The relative risks of factors in the cases compared with both the control groups were significant for roughness, aggressiveness, noisiness, and pica behaviour in the child, and for large families. Mothers' knowledge of the toxicity of common household products and drugs did not give significant risk differences between cases and controls. The majority of poisonings occurred during the summer months.     

Accidental kidney biopsies in psoriasis

Eight accidental kidney biopsies in psoriatics were obtained together with 429 liver biopsies. None of the biopsies showed signs of renal damage. All patients had severe psoriasis, six had been treated with methotrexate for 1-2-6 years, receiving total dosages from 660 to 1757 g.     

Accidental swallowing of endodontic instruments

Swallowing or aspiration of a foreign body is a complication that may arise from any procedure in the oral cavity performed without the use of a rubber dam. Two cases of swallowed endodontic instruments and possible complications are presented. Emphasis is given in the discussion on the early diagnosis and treatment and primarily on prevention with the use of rubber dam, an absolute essential during endodontic treatment.     

Occupational exposure to HIV, hepatitis B, hepatitis C, and tuberculosis

This article reviews risk of occupational exposure to bloodborne pathogens, specifically HIV, hepatitis B, and hepatitis C to healthcare workers. Information regarding assessing the risk of exposure, appropriate actions to take if an exposure occurs, the most recent recommendations for treatment and follow-up postexposure, and prevention strategies for avoiding exposure are presented. Additionally, current recommendations for the prevention of the transmission of tuberculosis in healthcare workers and the regulatory guidelines governing this topic are discussed.