Showing papers by "Lincoln Hospital published in 2004"

Low incidence of invasive cervical cancer among HIV-infected US women in a prevention program.

Abstract: Objective: To measure the incidence of invasive cervical cancer (ICC) in US women infected with HIV. Design: Multicenter prospective cohort study, conducted between October 1994, and September 2001. Setting: HIV research centers operating as six urban consortia in the Women's Interagency HIV Study. Subjects: A total of 2131 women (462 HIV seronegative, 1661 HIV seropositive, and eight seroconverters). Women with a history of hysterectomy or of cervical cancer at baseline evaluation were excluded. Intervention: Cervical cytology obtained at 6-month intervals, with a colposcopy referral threshold of atypia, followed by individualized treatment. Main outcome measure: ICC diagnoses obtained from study databases and regional cancer registries and confirmed by a gynecologic pathologist. Results: No incident ICC were observed in HIV seronegative women during 2375 woman-years of observation. During 8260 woman-years of observation, eight putative incident cases of cervical cancer were identified in HIV seropositive women, but only one was confirmed, yielding an incidence rate of 1.2/10 000 woman-years (95% confidence interval, 0.3-6.7/10 000 woman-years). The difference in incidence between HIV seropositive and seronegative women was not significant (P= 1.0). Conclusion: ICC is uncommon in HIV-infected US women participating in a regular prevention program.

Accounting for leadtime in cohort studies: evaluating when to initiate HIV therapies.

Abstract: Commonly reported comparisons of differences in disease progression according to disease staging at therapy initiation may be subject to bias if they do not account for the time it took the deferred group to reach the latter stage (that is, leadtime) and for previous events in those who initiate therapy at late stage (that is, unseen fast progressors) To estimate the impact of deferring initiation of highly active antiretroviral therapies (HAART) on time to clinical AIDS in the context of data from observational cohort studies, we describe a method that capitalizes on data from a pre-HAART period to multiply impute estimated leadtimes and the unseen events among fast progressors After accounting for leadtime and the unseen events, data from two large cohort studies (N=739) indicate that deferring HAART initiation until CD4 is below 200 cells/mm3 was detrimental compared to initiating between 201 and 350 (hazard ratio=197; 95 percent confidence interval [CI] 109, 354), and that failure to account for leadtime resulted in a 38 per cent higher hazard ratio In contrast, initiating HAART between 201 and 350 did not increase the hazard of AIDS compared to initiating with CD4 between 351 and 500cells/mm3 (hazard ratio=070; 95 per cent CI 035, 142) Methods presented here offer an approach to analysing prevalent cohort studies and provide procedures to maximize the usefulness of observational data Copyright © 2004 John Wiley & Sons, Ltd

Spontaneous uterine rupture as an unusual cause of abdominal pain in the early second trimester of pregnancy.

Abstract: A case of placenta percreta causing spontaneous uterine rupture is presented. This is a rare condition, which may present in the antepartum period as abdominal pain, with or without signs of hemorrhagic shock. This entity can lead to significant morbidity and mortality if not aggressively managed. A discussion follows on the pathophysiology, incidence, risk factors, presentation and management of this condition.

Effect of discontinuing antiretroviral therapy on survival of women initiated on highly active antiretroviral therapy.

Abstract: Objective To estimate the effect of discontinuing antiretroviral therapy (ART) on survival, among women who initiated highly active antiretroviral therapy (HAART). Design A multicenter cohort study. Methods A total of 951 HAART-initiated women were followed for total mortality between 1995 and 2002. The relative hazard (RH) of death attributable to discontinuing all ART was estimated using an inverse probability of treatment-weighted marginal structural Cox proportional hazards model, as well as standard Cox models. Results Three hundred and forty-three out of 951 women discontinued all ART during the 3187 person-years of follow-up, and 116 died. The RH of death attributable to discontinuation was 1.97 [95% confidence interval (CI) 1.17, 3.31] from the marginal structural Cox model. A RH of 1.49 (95% CI 0.94, 2.35) was observed using the same set of covariates in a standard Cox model. Conclusion An increased risk of mortality for those HAART initiators who discontinued ART was observed using a marginal structural Cox model. This increased risk was independent of measured treatment failure, and was greatly attenuated in a standard Cox model with time-varying covariates.

Prevalence of Human Herpesvirus-8 Salivary Shedding in HIV Increases with CD4 Count:

Abstract: Human herpesvirus-8 (HHV-8) is the etiologic agent of Kaposi's sarcoma (KS), which occurs in epidemic form in human immunodeficiency virus(HIV)-infected individuals. Saliva is the only mucosal fluid in which infectious HHV-8 has been identified, although factors associated with HHV-8 salivary shedding remain unclear. Our study performed PCR analysis for HHV-8 DNA in saliva (and other body fluids) in 66 HIV- and HHV-8-co-infected women without KS so that we could examine predictors for HHV-8 DNA detection. CD4 count was the most significant predictor of HHV-8 salivary shedding, with increased prevalence of HHV-8 salivary DNA at higher CD4 counts. The odds of salivary HHV8 shedding at CD4 counts > = 350 cells/microL was 63 times the odds of shedding at CD4 200. Analysis of these data suggests an increased potential for HHV-8 transmission early in HIV infection, with implications for HHV-8 prevention.

The promise of thalidomide: evolving indications.

Abstract: Thalidomide was first used in the late 1950s but it was withdrawn from the market in the 1960s for its notorious teratogenic effects. This drug was more recently rediscovered as a powerful immunomodulatory and antiinflammatory agent and was approved by the FDA in 1998 for treatment of erythema nodosum leprosum. Thalidomide has shown great promise in advanced or refractory multiple myeloma either alone or in combination with other agents. It has also demonstrated benefits in a wide variety of disparate conditions such as aphthous and genital ulcers, cancer cachexia, HIV, tuberculosis and chronic graft versus host disease. Thalidomide is being investigated for treatment of renal cell carcinoma, and liver and thyroid cancers. Better understanding of its many mechanisms of action has provoked great interest in its potential use for treatment of various disorders. This review focuses on thalidomide's mechanisms of action, biochemistry, pharmacokinetics and its use in erythema nodosum leprosum as well as multiple myeloma, graft versus host disease, and renal cell carcinoma.

Longitudinal Effect of Antiretroviral Therapy on Markers of Hepatic Toxicity: Impact of Hepatitis C Coinfection

Abstract: To characterize longitudinal hepatic toxicity of antiretroviral therapy in HIV-infected women with and without hepatitis C virus (HCV) infection, we measured alanine and aspartate aminotransferase values among women initiating highly active antiretroviral therapy (HAART). For 312 HIV/HCV coinfected women who received HAART for a mean of 1.8 years, the prevalence of elevated aminotransferase levels >3 times and >5 times the upper limit of normal (ULN) was low (<12% and <4%, respectively), and the prevalence of elevated aminotransferase levels declined over time. When we analyzed trends in aminotransferase levels according to type of HAART received among HCV-infected and uninfected women, we found that mean aminotransferase levels declined among 539 women receiving therapy with protease inhibitors (decreases of 5.34%–4.23% of the ULN per year; P values for trend of .007–.06), but mean values among 128 women receiving therapy with nonnucleoside reverse-transcriptase inhibitors remained stable (from decreases of 1.65% to increases of 7.57% of the ULN per year; P values of .19–.71). Our findings lend support to assertions that antiretroviral therapy is safe for women with HCV infection.

State of training in child neurology 1997-2002

Abstract: To the Editor: There are several other factors that may impact some of the issues revealed in the Child Neurology Workforce Study1 and the concerns expressed in Dr. Steven Rothman’s editorial2 on the current and future pediatric neurology workforce. The 1990s increase in number of generalists desired by managed care organizations may have resulted in a shortage of specialists that is only temporary. If the suggestion of a surplus of general pediatricians bears true, it will likely increase the number of future fellowship applicants. The more important issue, alluded to by both Child Neurology and General Pediatric Workforce studies,3 will the be the impact of an increase in number of female child neurologists (pediatric residency pool currently at over 60% female) on future needs, as female physicians prefer to work fewer hours …

Abdominal pain-an uncommon cause.

Abstract: CASE This 9-year-old female presented to the emergency department with a 3-week history of intermittent but frequent ‘‘stomach pain’’ with vomiting. Before this, she had been in good health but had been seen previously for the same reason 1 week ago. She has been admitted twice for abdominal pain but did not have any surgery. The episodes of stomach pain were numerous and increasing in frequency. The father related that the child had a weight loss of almost 7 lb and also that her appetite and energy level had decreased. She also reported epigastric fullness especially after meals, which improved after vomiting. She has no fever, diarrhea, or jaundice. Before arriving at our emergency department, the patient sought help elsewhere and was diagnosed with constipation. After these encounters and evaluations, she was treated with stool softeners and rectal enema. Because nothing seemed to work, the parents brought the patient to our emergency department. She was also referred to psychiatry for evaluation of eating disorder. Upon arrival, the child appeared reasonably healthy but was pale and unenergetic. On physical examination, the patient weighed 27 kg (25th percentile), and her vital signs were unremarkable, with a temperature of 36.88C, heart rate of 100 beats per minute, respiratory rate of 26 breaths per minute, and blood pressure of 122/ 74 mm Hg. Her oxygen saturation was 97% on room air by pulse oximetry. The patient’s abdomen was not distended. There were no visible scars or peristalsis. Bowel sounds were normal. Palpation revealed diffuse mild tenderness in the lower abdomen. There is no guarding, rigidity, or rebound tenderness. No palpable masses, organomegaly, or hernias were found. Examination of the rectum revealed no tenderness, no stool in the vault, no masses, and no blood. The genitalia, Tanner stage 2, were normal. The extremities were normal. Neurologic findings were unremarkable. A complete blood count showed a leukocyte count of 5200/ mm, with a differential of 36% neutrophils, 52% lymphocytes, 8.6% monocytes, and 2.4% eosinophils; hemoglobin of 14 g/dL; hematocrit of 41%; and platelet count of 301,000/mm. Sodium concentration was 138 mEq/L; potassium, 3.2 mEq/L; chloride, 99 mEq/L; bicarbonate, 27 mEq/L; blood urea nitrogen, 3 mg/dL; creatinine, 0.6 mg/dL; and glucose, 133 mg/dL. Her amylase is 94 IU/L and lipase 21 IU/L. Results of the urinalysis were normal, and liver function test results were slightly elevated and abnormal. Chest radiography findings were within normal limits, and flat and upright views of the abdomen showed no free air, no air in the right upper or right middle quadrant, moderate amount of stool in the descending colon, and rectum without any evidence of obstruction. Ultrasound showed marked fluid distension of descending duodenum (Fig. 1) and loss of angle between the superior mesenteric artery and aorta (Fig. 2). Upper gastrointestinal (GI) tract series showed a narrow segment at the level of third portion of duodenum with evidence of proximal distension (Fig. 3).

Ethics, education, and integrative medicine.

Abstract: Physician knowledge of complementary and alternative medicine can help patients make informed decisions regarding treatment plans. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.