Association of herpesvirus infections with T-lymphocyte-subset alterations, glomerulopathy, and opportunistic infections after renal transplantation

We studied the interrelation among herpes-virus infections, T-lymphocyte subsets, opportunistic infections, and renal histopathology in 28 recipients of renal allografts. All primary or reactivated herpesvirus infections occurring in the first three months after transplantation in recipients of cadaveric grafts accompanied persistent inversions in the ratio of OKT4 (helper/inducer) to OKT8 (cytotoxic/suppressor) lymphocytes. In the less heavily immunosuppressed recipients of organs of living related donors, these inversions were seen only in association with clinically apparent cytomegalovirus infections. Five of seven opportunistic infections occurred in patients with OKT4/OKT8 ratios of less than 1.0. Biopsy specimens from patients with renal dysfunction occurring in association with a low OKT4/OKT8 ratio frequently revealed glomerular damage rather than acute cellular rejection. Monitoring of T-lymphocyte subsets provides early evidence of herpesvirus infections and identifies patients at increased risk for opportunistic infection after renal transplantation.     

HIV Screening Practices and Hospital Characteristics in the U.S., 2009–2010

Objectives

The Centers for Disease Control and Prevention recommends HIV screening in U.S. health-care settings unless providers document a yield of undiagnosed HIV infections of <1 per 1,000 population. However, implementation of this guidance has not been widespread and little is known of the characteristics of hospitals with screening practices in place. We assessed how screening practices vary with hospital characteristics.

Methods

We used a national hospital survey of HIV testing practices, linked to HIV prevalence for the county, parish, borough, or city where the hospital was located, to assess HIV screening of some or all patients by hospitals. We used multivariate logistic regression analysis to assess the association between screening practices and hospital characteristics that were significantly associated with screening in bivariate analyses.

Results

Of 376 hospitals in areas of prevalence ≥0.1%, only 25 (6.6%) reported screening all patients for HIV and 131 (34.8%) reported screening some or all patients. Among 638 hospitals included, screening some or all patients was significantly (p<0.05) more common at teaching hospitals, hospitals with higher numbers of annual admissions, and hospitals with a high proportion of Medicaid admissions. In multivariable analysis, screening some or all patients was independently associated with admitting more than 15% of Medicaid patients and receiving resources or reimbursement for screening tests.

Conclusion

We found that few hospitals surveyed reported screening some or all patients, and failure to screen is common across all types of hospitals in all regions of the country. Expanded reimbursement for screening may increase compliance with the recommendations.Of the 1.2 million people in the United States who are infected with human immunodeficiency virus (HIV), it is estimated that 20% are unaware of their infection.¹ Early diagnosis of HIV infection allows infected people to obtain treatment that can prolong the quality and duration of their lives and can lead to reductions in high-risk behaviors and HIV transmission.^2–8 More generally, HIV infection satisfies the usual criteria for routine screening for infectious disease: it is a serious health disorder that can be diagnosed before symptoms appear; it can be detected by a reliable, noninvasive test; there are great potential health benefits to early detection; and the benefits of detection are large relative to the cost of screening.⁹ For these reasons, and to reduce the number of undiagnosed people living with HIV, in 2006 the Centers for Disease Control and Prevention (CDC) recommended HIV screening in all health-care settings for all individuals aged 13–64 years, regardless of risk, seen at facilities with an HIV prevalence of undiagnosed infections ≥0.1% among a sample of patients, and annual screening for patients known to be at risk for HIV infection.¹⁰Previous research has shown that the teaching status and size of hospitals, as well as the region and type of metropolitan area in which they are located, are associated with the availability of HIV testing in hospitals.¹¹ However, there are few published data about hospital characteristics that are associated with the adoption of CDC''s revised testing recommendations, and existing studies do not consider the impact of external factors, such as state regulations or third-party reimbursement policies, that might influence whether hospitals adopt the testing guidelines. Also unknown is how the screening practices of hospitals that serve larger proportions of low-income and minority patients compare with the practices of other hospitals.To address these open questions, we assessed the association between characteristics of hospitals and adoption of CDC''s revised recommendations for HIV testing in health-care settings using data from a national hospital survey of HIV testing practices in 2009. The results of that national survey, comparing responses in 2009 with those from 2004, have been previously reported.¹² However, that report did not consider factors that might influence screening practices, such as county HIV prevalence, information on state HIV testing regulations, and information on the percentage of admissions of low-income and minority patients at participating hospitals.     

Executive master of science in nursing program: incorporating the 14 forces of magnetism

This is the second in a 3-part series describing an executive master of science in nursing program. Part 1 described program development built on the American Organization of Nurse Executive's competencies and distinctive features of the students' online and on-site learning experiences. This article presents how the 14 Forces of Magnetism are integrated across the curriculum and the unique criteria for program admission. Finally, part 3 will describe use of the Robert Wood Johnson Executive Nurse Fellows Program as the model for scholarly activity and the use of Benner's Novice to Expert theory for program evaluation.