Suppression of hepatitis C virus (HCV) replication by hepatitis D virus (HDV) in HIV-infected hemophiliacs with chronic hepatitis B and C

Most hemophiliacs who are coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) have high serum levels of HCV RNA. To study the impact of multiple hepatitis virus infections, we evalated all eight chronic carriers of hepatitis B surface antigen (HBsAg) from a previously studied cohort of 99 hemophiliacs with chronic HIV and HCV infections. Stored serum or plasma samples were tested for antibody to hepatitis D virus (anti-HDV) by ELISA; qualitatively for HCV RNA, HBV DNA, and HDV RNA by the polymerase chain reaction (PCR); and quantitively for HIV RNA, HCV RNA, and hepatitis B virus (HBV) DNA by a quantitative branched DNA signal amplification assay. HCV RNA was detected in only one of five patients with HDV infections on a cross-sectional study, and this individual had low levels (<3.5×10⁵ genome eq/ml) of HCV RNA. In contrast, all three without HDV infections had high levels (>1.5×10⁷ genome eq/ml) of HCV RNA. HIV RNA was present in all eight patients. There was no correlation between the level of HIV RNA and the presence of hepatitis viruses. Three of the eight patients (38%) died of liver failure and another has hypersplenism with hypoprothrombinemia. We conclude that HDV infection appears to suppress HCV replication and that liver failure is common in adult HIV-infected hemophiliacs with chronic HCV and HBV infections. These findings have implications for the therapy of HCV-infected hemophiliacs who are HBsAg positive.This study was supported by the Brandywine Valley Hemophilia Foundation, and the Alice Livingston Trout Family Fund.Dr. Battegay was supported by the Swiss National Science Foundation, the Conrad Gessner Stipendium, and the Schweizerische Stiftung fur medizinisch biologische stipendien.     

Postoperative 30-day Mortality Following Surgical Resection for Colorectal Cancer in Veterans: Changes in the Right Direction

Temporal changes in short-term mortality following surgery for colorectal cancer (CRC) are unknown. We examined temporal changes in 30-day postoperative mortality, as well as changes in preoperative and postoperative disorders that could contribute to 30-day mortality. Using national Veterans Administration (VA) administrative data, we identified patients with CRC during 1987–2000 who received surgical resection. Cox proportional hazards models were used to evaluate the association between the risk of 30-day mortality and year of surgical resection, while adjusting for several preoperative disorders, disease comorbidity, as well as hospital surgical volume. A total of 32,621 patients were identified. The 30-day postoperative mortality declined from 4.7% during 1987–1988 to 3.9% during 1998–2000. Patients who received surgical resection during 1992–1994, 1995–1997, and 1998–2000 had a 14, 14, and 27% lower adjusted risk of 30-day mortality, respectively, compared with those resected in 1987–1988. Preoperative disorders associated with increased mortality included chronic pulmonary disease, congestive heart failure, diabetes, hemiplegia/paraplegia, moderate/severe liver disease, and renal disease. Significant declines were observed in several postoperative disorders including anesthesia complications and thromboembolism. An improvement in 30-day postoperative mortality following surgical resection for CRC was observed. Declining preoperative and postoperative disorders, as well as improvements in surgical care, could partly explain these findings.     

National Prevalence of Lifestyle Counseling or Referral Among African-Americans and Whites with Diabetes

Background  Modifiable risk factors such as diet and physical activity contribute to racial disparities among patients with diabetes. Despite this, little is known about how frequently physicians provide counseling or referral to address these risk factors, or whether such rates differ by patient race. Methods  We analyzed cross-sectional data from the 2002–2004 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. We used logistic regression to investigate the relationship between counseling/referral for nutrition or exercise and patient factors, provider factors, and geographic location, with a focus on whether counseling rates were independently associated with patient race. Results  Overall, counseling/referral for nutrition occurred in 36% of patient visits and counseling/referral for exercise occurred in 18% of patient visits. After adjusting for patient, physician, and practice characteristics, there was no statistically significant association between race and counseling/referral for nutrition (odds ratio for African-Americans compared to whites [OR] 1.00, 95% confidence intervals [CI] 0.71–1.41) or for exercise (OR 0.74, CI 0.49–1.11). Significant predictors of counseling/referral for both lifestyle interventions included younger patient age, private insurance, and treatment by a primary care provider. Conclusions  Rates of lifestyle modification counseling/referral were similarly low among African-Americans and whites in this national study. Our results highlight a need for interventions to enhance physician counseling for patients with diabetes, particularly those at high-risk for diabetes-associated morbidity and mortality, such as racial/ethnic minorities.     

Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) tube placement is the preferred method for long-term enteral feeding of patients who are unable to take food by mouth. Despite the widespread acceptance of the procedure, no large-scale study of the long-term outcomes of patients receiving PEG tubes has been reported. The objective of this study was to determine the survival of patients in whom PEG tubes are placed. DESIGN: Retrospective cohort study using data obtained from two computerized databases. SETTING: Department of Veterans Affairs hospitals. PATIENTS: Seven thousand three hundred sixty-nine patients who received a PEG tube in fiscal years 1990 through 1992. RESULTS: For the 7,369 patients, the mean age was 68.1 years and 98.6% were men. PEG tubes were most commonly placed in patients with cerebrovascular disease (18.9%), other organic neurologic disease (28.6%), or head and neck cancer (15.7%). Although the complication rate of the procedure itself was low (4%), because of the severity of their underlying disease, 1,732 patients (23.5%) died during the hospitalization in which the PEG tube was placed. The median survival of the full cohort was 7.5 months. CONCLUSIONS: This study documents the widespread placement of PEG tubes in severely ill patients, half of whom are in the terminal phase of their illness. Further study is needed to determine whether these patients benefit from PEG tube placement in terms of their quality of life and survival. From the Department of Veterans Affairs Health Services Research and Development (HSR&D) Field Program, and the Department of Medicine, Baylor College of Medicine, Houston, Tex. Supported by the Department of Veterans Affairs Health Services Research and Development Houston Field Program. Presented at the 95th annual meeting of the American Gastroenterological Association, New Orleans, La., May 15–18, 1994.     

Lessons Learned about Implementing Research Evidence into Clinical Practice

The mission of the Veterans Health Administration's (VHA) quality enhancement research initiative (QUERI) is to enhance the quality of VHA health care by implementing clinical research findings into routine care. This paper presents lessons that QUERI investigators have learned through their initial attempts to pursue the QUERI mission. The lessons in this paper represent those that were common across multiple QUERI projects and were mutually agreed on as having substantial impact on the success of implementation. While the lessons are consistent with commonly recognized ingredients of successful implementation efforts, the examples highlight the fact that, even with a thorough knowledge of the literature and thoughtful planning, unexpected circumstances arise during implementation efforts that require flexibility and adaptability. The findings stress the importance of utilizing formative evaluation techniques to identify barriers to successful implementation and strategies to address these barriers.     

Effects of nasal continuous positive airway pressure on oxygen body stores in patients with Cheyne-Stokes respiration and congestive heart failure

STUDY OBJECTIVES: The mechanism(s) by which nasal continuous positive airway pressure (CPAP) is effective in the treatment of Cheyne-Stokes respiration (CSR) in patients with congestive heart failure (CHF) remains uncertain, and may involve an increase in total oxygen body stores (dampening), changes in central and peripheral controller gain, and/or improvement in cardiac function. The purpose of this study was to evaluate the effects of nasal CPAP on total oxygen stores, as measured by the rate of fall of arterial oxyhemoglobin saturation (dSaO(2)/dt), to determine if dampening may play a role in the attenuation of CSR in patients with CHF. DESIGN: Prospective controlled trial. SETTING: University hospital. PATIENTS: Nine male patients (mean +/- SD age, 59 +/- 8 years) with CHF and a mean left ventricular ejection fraction (LVEF) of 16 +/- 4%. Interventions and measurements: All patients had known CSR, as identified on a baseline polysomnographic study. Patients then underwent repeat polysomnography while receiving nasal CPAP (9 +/- 0.3 cm H(2)O). The polysomnography consisted of recording of breathing pattern, pulse oximetry, and EEG. dSaO(2)/dt was measured as the slope of a line drawn adjacent to the falling linear portion of the arterial oxygen saturation (SaO(2)) curve associated with a central apnea. All patients underwent echocardiography and right-heart catheterization within 1 month of the study to measure LVEF and cardiac hemodynamics, respectively. RESULTS: There was a significant decrease in the apnea-hypopnea index (AHI) with nasal CPAP, from 44 +/- 27 events per hour at baseline to 15 +/- 24 events per hour with nasal CPAP (p = 0.004). When compared to baseline, dSaO(2)/dt significantly decreased with nasal CPAP from 0.42 +/- 0.15% to 0.20 +/- 0.07%/s (p < 0.001). The postapneic SaO(2), when compared to baseline, significantly increased with nasal CPAP, from 87 +/- 5% to 91 +/- 4% (p < 0.05). The preapneic SaO(2) did not significantly change, from a baseline of 96 +/- 2% to 96 +/- 3% with nasal CPAP (p = 0.8). When compared to baseline, the apnea duration and heart rate did not change with nasal CPAP. While there was a significant correlation noted between baseline postapneic SaO(2) and dSaO(2)/dt (r = 0.8, p = 0.02), no correlation was seen between baseline preapneic SaO(2) and dSaO(2)/dt (r = 0.1, p = 0.7). A significant correlation was noted between baseline dSaO(2)/dt and the AHI (r = 0.7, p = 0.02). With CPAP, there was a significant correlation noted between dSaO(2)/dt and the AHI (R = 0.7, p = 0.04), but no correlation was noted between dSaO(2)/dt and postapneic SaO(2) (R = 0.1, p = 0.8). CONCLUSION: Nasal CPAP significantly decreases dSaO(2)/dt and thus increases total body oxygen stores in patients with CSR and CHF. By increasing oxygen body stores, dampening may be one of the mechanisms responsible for the attenuation of CSR seen with nasal CPAP.     

Spritzenabszeß durch Neisseria perflava

Zusammenfassung Es wird über einen Spritzenabszeß in der Glutäalregion, hervorgerufen durchN. perflava, nach Injektion eines kortikosteroidhaltigen Mittels und oraler Gabe von D-Penicillamin berichtet. Als mögliche Infektionsmodi werden die hämatogene Aussaat vonN. perflava bei einer Tonsillitis oder unzureichende Desinfektion der Einstichstelle diskutiert.

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Injection abscess due to neisseria perflava

Summary A case of injection abscess in the gluteal region caused byN. perflava after injection of a preparation containing corticosteroid and after oral administration of D-penicillamine is reported. The haematogenous dissemination ofN. perflava in tonsillitis and insufficient disinfection of the injection site are discussed as possible routes of infection.

     

Time Course and Reversibility of Ethanol''s Suppressive Effects on Axon Sprouting in the Dentate Gyrus of the Adult Rat

Ethanol was administered chronically to adult rats in a liquid diet for 14 days preceding and for 5, 7, 8, 9, or 10 days following the unilateral destruction of the entorhinal cortex. Control groups received a diet of lab chow and water and were sacrificed at comparable survival times. An additional experimental group was given ethanol until 9 days after the lesion, then switched to lab chow and water and sacrificed 1 day later. Coronal sections through the dorsal hippocampal formation were stained and analyzed histochemically for the localization of acetylcholinesterase (AChE). Quantitative measurements of the histochemical patterns in the molecular layer of the dentate gyrus were obtained. Ethanol exposure inhibited the withdrawal of the acetylcholinesterase-stained septohippocampal fibers and limited the typical lesion-induced expansion of the pale-staining commissural/associational zone in the molecular layer of the denervated dentate gyrus. However, abstinence from ethanol for just 24 h released the inhibitory effect on the acetylcholinesterase-staining fibers, resulting in a significant expansion of the commissural/associational zone.     

Blood Pressure and Alcohol Intake in Heart Patients

The association between alcohol consumption and blood pressure has been studied in 2025 male and 282 female patients undergoing diagnostic coronary angiography. The increase in amount of alcohol consumed correlated with higher systolic and diastolic blood pressure; this effect was especially pronounced in men over 50 years of age. The association was less marked in male patients under 50 years old, in women, and in patients on antihypertensive medication. Readings in the range of definitive hypertension were more prevalent among older patients consuming six or more drinks daily than in abstainers of the same age group.