From <@uga.cc.uga.edu:owner-mednews@ASUACAD.BITNET> Sun Apr 2 13:14:53 1995 with BSMTP id 8703; Sun, 02 Apr 95 13:04:27 EDT UGA.CC.UGA.EDU (LMail V1.2a/1.8a) with BSMTP id 4021; Sun, 2 Apr 1995 13:04:15 -0400 HICNet Medical News Digest Sun, 02 Apr 1995 Volume 08 : Issue 13 Today's Topics: Daily AIDS News Summary +------------------------------------------------+ ! ! ! Health Info-Com Network ! ! Medical Newsletter ! +------------------------------------------------+ Editor: David Dodell, D.M.D. 10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA Telephone +1 (602) 860-1121 FAX +1 (602) 451-1165 Internet: mednews@stat.com Bitnet: ATW1H@ASUACAD Mosaic WWW *Asia/Pacific: http://biomed.nus.sg/MEDNEWS/welcome.html *Americas: http://cancer.med.upenn.edu:3000/ *Europe: http://www.dmu.ac.uk/ln/MEDNEWS/ Compilation Copyright 1995 by David Dodell, D.M.D. All rights Reserved. License is hereby granted to republish on electronic media for which no fees are charged, so long as the text of this copyright notice and license are attached intact to any and all republished portion or portions. The Health Info-Com Network Newsletter is distributed biweekly. Articles on a medical nature are welcomed. If you have an article, please contact the editor for information on how to submit it. If you are interested in joining the automated distribution system, please contact the editor. Associate Editors: E. Loren Buhle, Jr. Ph.D. Dept. of Radiation Oncology, Univ of Pennsylvania Tom Whalen, M.D., Robert Wood Johnson Medical School at Camden Douglas B. Hanson, Ph.D., Forsyth Dental Center, Boston, MA Lawrence Lee Miller, B.S. Biological Sciences, UCI Dr K C Lun, National University Hospital, Singapore W. Scott Erdley, MS, RN, SUNY@UB School of Nursing Jack E. 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Copyright 1995, Information, Inc., Bethesda, MD In this issue: ********************************************************************* "India to Become AIDS Epicentre, Conference Told" "Treatment of Cytomegalovirus Retinitis With an Intraocular Sustained-Release Ganciclovir Implant: a Randomized Controlled Clinical Trial" "Gene Therapy and Immune Restoration for HIV Disease" "Debugging Blood" "Adverse Cutaneous Reactions to Trimethoprim-Sulfamethoxazole in Patients with the Acquired Immunodeficiency Syndrome and Pneumocystis Carinii Pneumonia" "Increases in CD4 T Lymphocytes with Intermittent Courses of Interleukin-2 in Patients with Human Immunodeficiency Virus Infection" "HIV Counseling and Testing -- United States, 1993" "Mechanism of Inhibition of HIV-1 Reverse Transcriptase by Nonnucleoside Inhibitors" "Changes in Taste Associated with Intravenous Administration of Pentamidine" "Italian Surgeon Gets AIDS Virus from Scalpel Cut" "The AIDS Knowledge Base: A Textbook on HIV Disease from the University of California, San Francisco, and the San Francisco General Hospital" "Self-Insemination May Carry Risk of HIV Infection" "Primary Prevention of Cryptococcal Meningitis by Fluconazole in HIV-Infected Patients" "Storing One's Own Blood for Surgery Strains Medical Resources, Study Says" "HIV in the Elderly: Not Just from Transfusion" "AIDS Clinical Trials: Why They Have Recruiting Problems" "Preventing AIDS: Theories and Methods of Behavioral Interventions" "HIV-Associated Histoplasmosis with Pulmonary Manifestations" "Intestinal Mycobacteria in African AIDS Patients" "Heart Muscle Disease Related to HIV Infection: Prognostic Implications" ********************************************************************* "India to Become AIDS Epicentre, Conference Told" Reuters (03/04/95) In five years, India will be the region most affected by AIDS, an Australian population conference was told on Saturday. India will overtake Africa as the "epicentre of AIDS" and will probably have more HIV-infected people than the rest of the world combined, said Roger Short, a Monash University biology professor, speaking at the meeting of Australians for an Ecologically Sustainable Population. Short also said that during the next 30 years, AIDS will rapidly spread into Asian countries, especially India. The disease, he added, will have little impact on the world's population levels. The National AIDS Control Organization estimates that 1.62 million of India's 850 million citizens are infected with HIV--up 60 percent from 1993. "Treatment of Cytomegalovirus Retinitis With an Intraocular Sustained-Release Ganciclovir Implant: a Randomized Controlled Clinical Trial" J.A.M.A. (03/01/95) Vol. 267, No. 9, P. 682e In a randomized controlled clinical trial of the safety and efficacy of a ganciclovir implant, AIDS patients with newly diagnosed cytomegalovirus (CMV) retinitis were either treated immediately with the implant or deferred treatment. Of the 26 patients (30 eyes), the average time to progression of retinitis was 15 days in the deferred treatment group--compared to 226 days in the immediate treatment group. A total of 39 primary implants and 12 exchange implants were placed in immediate-treatment eyes, deferred-treatment eyes, or contralateral eyes that developed CMV retinitis. In 34 of 39 eyes, final visual acuity was at least 20/25. The risk of developing CMV retinitis in the other eye was 50 percent after six months. Eight patients developed biopsy-proven visceral CMV disease. The researchers concluded that the ganciclovir implant is effective for the treatment of CMV retinitis. Patients with unilateral CMV retinitis, who are treated with the implant, will likely develop the disease in the other eye, and some patients will develop visceral CMV disease, the study concluded. "Gene Therapy and Immune Restoration for HIV Disease" Lancet (02/18/95) Vol. 345, No. 8947, P. 427 Bridges, Sandra H.; Sarver, Nava Recent studies have begun to explore innovative strategies that can target the viral, immunological, and cellular components of HIV disease. Current studies of HIV gene therapy involve gene transfer into mature CD4 T cells. Efforts, however, are being made to deliver antiviral genes to pluripotent hematopoietic stem cells to guarantee a renewable supply of HIV-protected cells for the life of the patient. Immune restoration strategies deal with the transfer of various cell populations to HIV-positive people with the purpose of restoring immune function. It is generally agreed that restoring immune cells is more likely to have a therapeutic effect if the cells are altered to resist HIV infection. Nucleic acid-based therapeutic vaccines involve direct delivery of HIV genes into the patient's tissue to imitate natural infection, and thus, enhance immune responses against HIV. The combined use of gene therapy, adoptive immune therapy, and nucleic acid-based immune enhancement represents a comprehensive treatment regimen that focuses on the key elements of HIV disease--the virus and the immune system. "Debugging Blood" Science News (02/11/95) Vol. 147, No. 6, P. 92 Adler, Tina All U.S. blood banks must screen donations for syphilis, hepatitis B and C, two types of HIV, two types of human T cell leukemia virus, and other infectious agents. However, most HIV-tainted blood that reaches transfusion recipients comes from recently infected people who have not yet developed antibodies to HIV. Although HIV researchers have developed tests that detect the virus earlier in infection, the more sensitive screens may not prove cost-effective if widely used, said an advisory panel to the National Institutes of Health last month. The panel also recommended that blood banks stop doing a test that measures the activity of the enzyme alanine aminotransferase (ALT) in the blood. ALT enters the bloodstream in response to liver damage, such as that caused by hepatitis. Other factors, however, such as heavy alcohol consumption and obesity, that do not make people unsuitable donors may also increase ALT activity. Each year, blood banks discard about 200,000 units and turn away 150,000 potential donors because of elevated ALT readings. The hepatitis B core antibody (anti-HBc) tests--developed to detect non-A, non B hepatitis virus--was found to indirectly identify HIV-tainted blood that would otherwise go undetected. The panel concluded these detections compensate for the test's high false positive rate. "Adverse Cutaneous Reactions to Trimethoprim-Sulfamethoxazole in Patients with the Acquired Immunodeficiency Syndrome and Pneumocystis Carinii Pneumonia" J.A.M.A (03/01/95) Vol. 273, No. 9, P. 682b In a retrospective study, researchers assessed the value of clinical and laboratory parameters for predicting trimethoprim-sulfamethoxazole-induced skin reactions and the effects of continued therapy in AIDS patients. The reasons why AIDS patients are predisposed to cutaneous drug reactions are poorly understood. Of the 38 patients treated with trimethoprim-sulfamethoxazole, 18 developed cutaneous reactions in an average of 11 days. Such treatment was continued in 19 of the 20 patients who did not develop skin reactions. No clinical or laboratory parameters were found to be predictive of trimethoprim-sulfamethoxazole-induced cutaneous reactions. By treating through hypersensitivity, 67 percent of the patients, who otherwise might have had to stop therapy with trimethoprim-sulfamethoxazole, were able to continue treatment. "Increases in CD4 T Lymphocytes with Intermittent Courses of Interleukin-2 in Patients with Human Immunodeficiency Virus Infection" N.E.J.M. (03/02/95) Vol. 332, No. 9, P. 567 Kovacs, Joseph A.; Baseler, Michael; Dewar, Robin J. et al. To determine the value of intermittent courses of interleukin-2 for the long-term management of HIV infection, Kovacs et al. focused on HIV-infected patients with a moderate suppression of the immune system. Based on previous work, such patients are more likely to have a response to immunomodulators than patients with severely impaired immune function. Twenty-five patients received interleukin-2 for five days every 8 weeks during a period of seven to 25 months. In addition, all patients received at least one antiviral agent. Therapy with interleukin-2 was linked to at least a 50 percent increase in the number of CD4 cells in six of the 10 patients with CD4 counts higher than 200. For the remaining 15 patients, who had CD4 counts of 200 or less, interleukin-2 therapy was associated with increased viral activation, few immunologic improvements, and significant toxic effects. Kovacs et al. concluded that intermittent interleukin-2 therapy can reverse some of the immunologic abnormalities associated with HIV infection in patients with CD4 counts above 200. HIV Counseling and Testing -- United States, 1993 MORBIDITY AND MORTALITY WEEKLY REPORT Centers for Disease Control and Prevention March 10, 1995 Vol. 44, No. 9 Counseling and testing (CT) are important components of state and local human immunodeficiency virus (HIV)-prevention programs (1). Analysis of national data sources indicates that HIV-antibody tests are obtained from a variety of testing sites, including private physicians, hospitals, and outpatient clinics (66.7%), and publicly funded sites (33.1%) (2). This report uses data from CDC's 1993 Behavioral Risk Factor Surveillance System (BRFSS) to examine variations in rates of use of private and public HIV CT sites by state. In 1993, a total of 49 states and the District of Columbia participated in the BRFSS, a state-specific population-based, random-digit-dialed telephone survey that collects information monthly from U.S. adults aged greater than or equal to 18 years. Thirteen questions about HIV/AIDS-related knowledge and attitudes and HIV-antibody testing history during the preceding year were asked only to respondents aged less than or equal to 65 years. In 1993, a total of 84,039 persons responded to these questions (state-specific range: 993 to 3667). The state-specific median percentage of 82% of eligible respondents completed interviews (3). Data for each state were weighted by demographic characteristics and by selection probability; results are representative of persons aged 18-65 years in each state. Confidence intervals for percentages and estimated numbers of persons tested were based on standard errors that accounted for complex survey design (4). A median of 25.5% of persons (range: 14.4% [Iowa] to 37.5% [Alaska]) answered yes to the question: "Except for donating or giving blood, have you ever had your blood tested for the AIDS virus infection?" (Table 1). The number (weighted estimate) of adults who had ever been tested for HIV was highest in California (6.3 million). A median of 9.6% of persons (range: 4.1% [Maine and South Dakota] to 16.9% [District of Columbia]) reported obtaining HIV-antibody tests primarily for diagnostic reasons* (Table 1). Persons categorized as having obtained diagnostic HIV-antibody tests were identified by one of three responses to the question "What was the main reason you had your last AIDS blood test?": "to find out if infected," "because of referral by a doctor or health department or sex partner," or "for routine checkup**." In 43 states and the District of Columbia, at least 50.0% (median: 60.9%) of respondents had obtained their last diagnostic test from a private physician, health maintenance organization, or private outpatient clinic (Table 2). A median of 16.2% of persons (range: 5.0% [North Dakota] to 37.6% [Mississippi]) had obtained their last diagnostic test at a publicly funded prevention site (including health departments; AIDS, sexually transmitted disease [STD], or tuberculosis clinics; and drug-treatment programs). The estimated number of persons who obtained a diagnostic test at a publicly funded site during the preceding year correlated with the number of tests reported to CDC's HIV Counseling and Testing System by publicly funded sites in each state (5) (correlation coefficient=0.96; p less than 0.01). A median of 60.7% of persons who had obtained their most recent diagnostic HIV-antibody test at a publicly funded site (range: 30.8% [New Jersey] to 95.7% [Oklahoma]) received counseling with their test results (Table 2). In comparison, a median of 28.2% of persons who had obtained their tests from a private site (range: 7.7% [Kentucky] to 77.3% [Oklahoma]) also received counseling. In most (90%) of the reporting areas, the number of persons who received counseling with their HIV test results was greater than or equal to 1.5 times greater for persons tested at publicly funded sites than those tested at private sites. Reported by the following BRFSS coordinators: S Jackson, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MS, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; F Newfield, MPH, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; R Guest, MPH, Indiana; P Busick, Iowa; M Perry, Kansas; K Bramblett, Kentucky; D Hargrove-Roberson, MSW, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; R Lederman, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; E Jones, MS, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; P Jaramillo, MPA, New Mexico; C Maylahn, MPH, New York; G Lengerich, MD, North Carolina; D Young, MS, North Dakota; E Capwell, PhD, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; J Romano, MPH, Pennsylvania; J Hesser, PhD, Rhode Island; M Lane, MPH, South Carolina; B Miller, South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; S Carswell, MA, Virginia; K Holm, MPH, Washington; F King, West Virginia; E Cautley, MS, Wisconsin. Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs; Behavioral Risk Factor Surveillance Br, Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The findings from the 1993 BRFSS document a high degree of state-specific variability in self-reported HIV-antibody tests in the United States. This variability may reflect state-specific differences in such factors as the prevalence of HIV infection and HIV testing in high-risk groups, the presence and impact of HIV-prevention programs, and age distribution. The BRFSS estimates of the number of persons last tested for voluntary or diagnostic reasons at a publicly funded clinic correlated highly with estimates from CDC's HIV Counseling and Testing System, and the median percentage of respondents ever tested for HIV (25%) is consistent with estimates based on CDC's National Health Interview Survey (22%). Health-care visits to seek and obtain HIV tests are important opportunities to counsel persons about the risk for HIV infection and methods to reduce such risk (1). The data in this report indicate that, in most states, approximately threefold more persons reported having obtained their HIV test from a private provider than from a public site; however, persons who had obtained their úÿ úÿ(Continued from last message) test from a private provider were substantially less likely to have reported receiving counseling than those who obtained tests at a public site. This finding underscores the need for physicians and other health-care providers in private settings to offer HIV counseling at the time patients receive their HIV test results. The findings in this report are subject to at least two limitations. First, the sample size of persons who reported having had an HIV-antibody test in individual states did not enable stratification by other respondent characteristics. For example, state-specific sample sizes precluded analysis to determine whether specific high-risk populations that obtained HIV-antibody testing also received counseling. Second, because the BRFSS is a telephone-based system, some persons at high risk for HIV infection most likely were excluded from the survey. The BRFSS is a unique source for information about HIV-antibody testing behaviors of U.S. adults--particularly patterns of HIV testing outside of public clinics--and can be used both at the federal and state levels to improve HIV-prevention and intervention programs. Questions about CT in the 1993 BRFSS were developed based on input from state health departments; subsequent BRFSS surveys may incorporate additional HIV-related behavioral questions. References 1. Hinman AR. Strategies to prevent HIV infection in the United States. Am J Public Health 1991;81:1557-9. 2. CDC. HIV counseling and testing services from public and private providers--United States, 1990. MMWR 1992;41:743,749-52. 3. CDC. 1993 BRFSS quality control report. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994. 4. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.30 [Software documentation]. Research Triangle Park, North Carolina: Research Triangle Institute, 1989. 5. CDC. HIV counseling and testing data system: national profile, 1993. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994. * For this study, diagnostic HIV-antibody tests were defined as those administered primarily to learn infection status rather than voluntary tests to qualify for insurance, military induction, immigration, marriage license application, or employment. ** This response was included in "diagnostic" reasons to avoid excluding respondents who initiated a routine examination to determine whether they were infected with HIV. Clarification: Vol. 43, Nos. 51 & 52 The notice to readers "Recommended Childhood Immunization Schedule--United States, January 1995" (pages 959-960) stated that infants born to hepatitis B surface antigen (HBsAg)-positive mothers should receive immunoprophylaxis with 0.5 mL of hepatitis B immune globulin (HBIG) and 0.5 mL of hepatitis B vaccine administered at separate sites. Hepatitis B vaccines licensed in the United States are produced by Merck and Co., Inc. (Rahway, New Jersey), and SmithKline Beecham (Philadelphia) and are available in various concentrations. The recommended dose of hepatitis B vaccine for infants varies by manufacturer and HBsAg status of the mother (Table 1). Merck and Co., Inc., recommends 2.5 ug of Recombivax HB (registered) for infants of HBsAg-negative mothers and 5.0 ug for infants of HBsAg-positive mothers; SmithKline Beecham recommends 10 ug of Engerix-B (registered) regardless of the mother's HBsAg status. Providers should know the HBsAg status of an infant's mother and consult the product package insert for the recommended vaccine dose. Providers also should be aware that the Food and Drug Administration recently lowered the age-appropriate dose of Engerix-B (registered) from 20 ug to 10 ug for adolescents 11-19 years of age (Table 1) (1). Reference 1. Smithkline Beecham Pharmaceuticals. Brief summary of prescribing information: Engerix-B (registered) [Package insert]. Philadelphia: Smithkline Beecham Pharmaceuticals, 1995. Addendum: Vol. 44, No. 8 In the article, "Exposure of Passengers and Flight Crew to Mycobacterium tuberculosis on Commercial Aircraft, 1992-1995," the following names should be added to the credits ("reported by") on the sixth line on page 139: A Ignacio, MD, D Morishige, RL Vogt, MD, State Epidemiologist, Communicable Disease Div, Hawaii Dept of Health. Errata: Vol. 44, No. 8 In the article, "Exposure of Passengers and Flight Crew to Mycobacterium tuberculosis on Commercial Aircraft, 1992-1995," on page 138 in the first sentence under investigation 3, the length of flight is incorrect. The sentence should read, "In March 1993, a foreign-born passenger with pulmonary TB traveled on a 4 1/2-hour flight from Mexico to San Francisco." In the article, "Use of Safety Belts--Madrid, Spain, 1994," the first sentence on page 151 should read, "Of 1063 phone numbers called to identify eligible households, 294 (27.7%) could not be contacted (no one answered or the line was busy), and 185 were excluded (because the phone number was commercial, no one aged greater than or equal to 18 years was in the home at the time of the call, or respondents never traveled by vehicle)." "Mechanism of Inhibition of HIV-1 Reverse Transcriptase by Nonnucleoside Inhibitors" Science (02/17/95) Vol. 267, No. 5200, P. 988 Spence, Rebecca A.; Kati, Warren M.; Anderson, Karen S. et al. Spence et al. studied the mechanism of inhibition of HIV-1 reverse transcriptase by three nonnucleoside inhibitors. Nevirapine, O-TIBO, and CI-TIBO each bind to a hydrophobic pocket in the enzyme-DNA complex near the active site catalytic residues. The researchers used pre-steady-state kinetic analysis to determine the mechanism of inhibition by these noncompetitive inhibitors. Analysis of the pre-steady-state burst of DNA polymerization showed that the inhibitors blocked the chemical reaction, but did not interfere with nucleotide binding or the nucleotide-induced conformational change. In the presence of saturating concentrations of the inhibitors, however, the nucleoside triphosphate bound tightly but nonproductively. The findings suggest that an inhibitor that combines the functionalities of a nonnucleoside inhibitor and a nucleotide analog could bind very tightly and specifically to reverse transcriptase and could be very useful in the treatment of AIDS. "Changes in Taste Associated with Intravenous Administration of Pentamidine" Glover, Jennifer; Dibble, Suzanne; Miaskowski, Christine In an attempt to describe the incidence of taste changes associated with intravenous pentamidine isethionate (IV PENT) treatment and to determine the factors that affect the taste changes, Glover et al. studied 18 adult males with AIDS who were receiving outpatient treatment for Pneumocystis carinii pneumonia (PCP) with IV PENT. All of the participants reported an unpleasant taste after treatment. While 89 percent described the taste as metallic, 67 percent experienced a bitter taste. The participants said that factors such as sweet foods and drinks, juice, and chocolate improved the unpleasant taste. The items most frequently cited as making the taste worse were milk and tap water. The study suggests that taste changes associated with IV PENT occur and produce accompanying decreases in food intake and appetite. Healthcare providers caring for patients receiving IV PENT should assess for alterations in taste and inform patients of them, as well as the concomitant decrease in appetite. "Italian Surgeon Gets AIDS Virus from Scalpel Cut" Reuters (03/10/95) Holmes, Paul While operating on an HIV-infected patient, an Italian surgeon contracted the virus--representing the first documented case of transmission under such circumstances, said researcher Dr. Giuseppe Ippolito on Friday. Ippolito is the head of a team at Spallanzani Hospital in Rome that has conducted one of only two major studies on the occupational risk of AIDS among health care workers. Ippolito said the accident took place in a hospital last year when the scalpel cut through the surgeon's glove. The surgeon was immediately tested for HIV. The results were negative, but a follow-up test was positive. "We excluded all other means of transmission," Ippolito said. In Italy, surgical patients are not routinely tested for HIV, and can only be tested, with their consent, when a risk is suspected. "The AIDS Knowledge Base: A Textbook on HIV Disease from the University of California, San Francisco, and the San Francisco General Hospital" N.E.J.M. (03/02/95) Vol. 332, No. 9, P.617 Klein, Robert S. "The AIDS Knowledge Base," the work of 102 contributing authors, focuses on AIDS as it is presented and managed in the United States. It is intended to be relevant to all geographic regions for a wide range of health care professionals and motivated nonprofessionals. The book's 11 sections address the pathogenesis and management of HIV infection, as well as legal, economic, and ethical issues. Because many of the authors are from San Francisco, however, there is a tendency to base general statements on experience with middle class men. Still, information that is relevant to all persons affected by AIDS is usually included. Some particularly comprehensive chapters are those on the methods of testing for HIV antibody or antigen and on rochalimaea, and the section on the pulmonary aspects of AIDS. "Self-Insemination May Carry Risk of HIV Infection" Washington Post (03/15/95) P. A3 There is a risk of contracting HIV for women who practice self-insemination with sperm that has not been properly screened for HIV, a researcher has cautioned. Another researcher, however, said there have been no reported cases of HIV infection through artificial insemination since 1986, and said a woman's risk of becoming infected in such a fashion is "probably remote." Although the Centers for Disease Control and Prevention (CDC) recommends that semen donors be tested for HIV, it is not known how many actually are, said Mary E. Guinan of the CDC's HIV-AIDS office, writing in the Journal of the American Medical Association. "Artificial insemination is safe but not completely so," she wrote. Still, in another study reported in the same journal, Maria Rosario G. Araneta found that seven of 199 women artificially inseminated with semen from five HIV-infected men between 1981 and 1985 tested HIV-positive. The test for HIV antibody became available in 1985, and no cases of infection through artificial insemination have been reported since then, said Araneta, an epidemiologist with the Naval Health Research Center in San Diego. "Primary Prevention of Cryptococcal Meningitis by Fluconazole in HIV-Infected Patients" Lancet (03/04/95) Vol. 345, No. 8949, P. 548 Quagliarello, Vincent J.; Viscoli, Catherine; Horwitz, Ralph I. Quagliarello et al.'s study of the use of oral fluconazole provides evidence for the use of the drug in preventing a first episode of cryptococcal meningitis in HIV-infected people. During the six months before lumbar puncture--a method of specific diagnosis--two of the 18 subjects with cryptococcal meningitis and 26 of the 72 controls were exposed to fluconazole. This finding indicates a 92 percent protective efficacy for fluconazole exposure. The researchers concluded that fluconazole decreases the risk of a first episode of cryptococcal meningitis in people with CD4 counts less than 250. Because the patients were exposed to fluconazole for an average of 30 days, it is possible that a significant protective effect could be achieved with less than daily use. "Storing One's Own Blood for Surgery Strains Medical Resources, Study Says" Wall Street Journal (03/16/95) P. B6 Rundle, Rhonda L. The increasingly popular practice of autologous donation--or banking one's own blood for possible use during surgery--is expensive, strains medical resources, and offers little benefit to society, a new study concludes. The study, published in this week's New England Journal of Medicine, analyzes a medical procedure that many blood banks and physicians began to promote in the early 1980s after stories spread about people who became infected with HIV through a blood transfusion. In light of the improvements in the safety of the blood supply over the past decade, however, autologous blood may be a poor use of scarce medical resources, according to Dr. Jeff Etchason, the study's lead author, a staff physician at the West Los Angeles Veterans Affairs Medical Center. An editorial that accompanies the study, however, says that "the peace of mind that comes from having control over the risk of AIDS and other potentially harmful effects of transfusion is immeasurable." The study concludes that the incremental cost-effectiveness of autologous blood, expressed as dollars per quality-adjusted year of life saved, ranged from $235,000 to more than $23 million. "HIV in the Elderly: Not Just from Transfusion" AIDS Clinical Care (03/95) Vol. 7, No. 3, P. 25 Two small studies add to the data known about the small, but growing population of HIV-infected people who are aged 60 or older. The first study analyzed the charts of 27 men and 5 women ages 60 to 83 at an inner-city Atlanta hospital. In 15 of the 20 cases where the source was known, HIV was transmitted through sex or injection drug use. Transfusion was the cause in only three cases. Diagnosis was frequently delayed because the patients were not considered to be at risk for HIV. The second study looked at serum samples taken from 170 elderly patients who died between 1992 and 1993 at Harlem Hospital in New York. The researchers found evidence of HIV infection in 6 percent of the men and 9 percent of the women. Once again, most or all of the cases were unsuspected, and many of the patients had no known risk factors. Clinicians should be aware of the potential for HIV in the elderly and should take a sexual history regardless of age. There is evidence that older sexually active people--including those with HIV risk factors--have much lower rates of condom use than younger people. "AIDS Clinical Trials: Why They Have Recruiting Problems" AIDS Treatment News (02/17/95) No. 217, P. 1 Mirken, Bruce AIDS clinical trials often have difficulty enrolling the number of volunteers needed. "The majority of our trials take a lot longer than anybody expected to enroll. My guess is that this is what's happening across the country." said Ronald Mitsuyasu, director of the University of California at Los Angeles' Center for Clinical AIDS Research and Education. Obstacles to enrollment in AIDS trials can be divided into two categories: the publicity or outreach efforts used to recruit volunteers, and the design of the trials themselves. One problem with publicity is that drug companies are often reluctant to release data on a drug, which makes it difficult for recruiters to give potential volunteers the data they need to feel safe in the study. Another is the lack of clear guidance from the Food and Drug Administration on what publicity materials should or should not say--which can lead some trial sponsors to err on the side of caution by not saying enough. People, however, will not be attracted to a trial whose design is inherently unappealing to patients or whose inclusion/exclusion of criteria keeps out to many possible volunteers. Mitsuyasu noted that "patients are almost burnt out, and maybe somewhat pessimistic about what trials can do for them." "Preventing AIDS: Theories and Methods of Behavioral Interventions" N.E.J.M. (03/02/95) Vol. 332, No. 9, P.617 Fleming, Patricia "Preventing AIDS: Theories and Methods of Behavioral Interventions," edited by Ralph J. DiClemente and John L. Peterson, is a series of essays detailing behavioral interventions and assessing current research on preventing HIV infection among populations including runaways, heterosexual men and women, and adolescents. The first six chapters describe behavioral-science research methods. These chapters are based on the health-beliefs model, in which change in a person's behavior occurs only if that person perceives a risk and believes that the outcome can be affected through behavior change. In the nine chapters about research on HIV prevention in populations at high risk, the authors accent what is needed and recommend methods to evaluate the outcomes. The editors call for the promotion of self-management to reduce risk at the individual level, and the promotion of sustained changes in social norms through community-level interventions. "HIV-Associated Histoplasmosis with Pulmonary Manifestations" J.A.M.A. (03/08/95) Vol. 273, No. 10, P. 758k Wockel et al. present a case in which a 35-year-old man experienced a general deterioration of health--characterized by symptoms including weight loss, fever, and abdominal pain. The man learned in 1991 that he was infected with HIV. He was given tuberculostatic drugs because miliary tuberculosis was suspected. As his condition worsened, however, he was thought to have Pneumocystis pneumonia, and high doses of co-trimoxazole were administered. Acid-Schiff reaction and Grocott staining revealed several histoplasma in alveolar macrophages and connective tissue. Therapy was shifted to itraconazole, but changed to liposomal amphotericin B two weeks later because of renewed fever. After six weeks of treatment, the patient was symptom-free and the radiological changes had largely regressed. Itraconazole therapy is being continued to prevent recurrence. "Intestinal Mycobacteria in African AIDS Patients" Lancet (03/04/95) Vol. 345, No. 8949, P. 585 Pankhurst, C.L.; Luo, N.; Kelly, P. et al. Infection with both HIV and Mycobacterium tuberculosis has had a significant impact on the epidemiology of tuberculosis (TB) in sub-Saharan Africa. Pankhurst et al. conducted a cross-sectional study of the prevalence of mycobacteria in 120 fecal samples taken from 69 patients with HIV-related diarrhea attending the University Teaching Hospital in Lusaka. Fecal specimens from seven of the 69 patients grew mycobacteria--two had Mycobacterium avium complex (MAC), four had M. tuberculosis, and one had M. flavescens. In a parallel study, the researchers studied fecal specimens from HIV-infected patients in London. Similar rates of recovery of mycobacteria were found, with seven of the isolates being MAC and one M. tuberculosis. One half of the stool-positive cases developed disseminated disease during the 6-12 months of follow-up. Pankhurst et al. concluded that M. tuberculosis and MAC are found in the gut of 10 percent of African patients with HIV-related diarrhea. There is, however, little evidence of the small intestinal mycobacterial disease found in AIDS patients in industrialized countries. Despite high rates of infection in people with AIDS, M. tuberculosis is not a significant contributor. "Heart Muscle Disease Related to HIV Infection: Prognostic Implications" J.A.M.A. (03/08/95) Vol. 273, No. 10, P. 758h To determine the natural course of heart muscle disease in HIV-infected patients, Currie et al. studied HIV-infected adults to detect myocardial dysfunction and time to death. Forty-four of the 296 subjects were diagnosed with cardiac dysfunction. In contrast to other forms of cardiac dysfunction, dilated cardiomyopathy was strongly associated with a CD4 cell count less than 100. Compared to those with normal hearts, patients with dilated cardiomyopathy had significantly reduced survival rates. While 101 days was the average survival time for those patients with cardiomyopathy, those with normal hearts and a CD4 cell úÿ úÿ(Continued from last message) count less than 20 lived 472 days. There were no significant differences in survival for participants with borderline left or isolated right ventricular dysfunction. Even with the reduced cell count with which dilated cardiomyopathy is associated, the prognosis for HIV-infected patients with dilated cardiomyopathy is poor. Isolated right and borderline left ventricular dysfunction, however, are not linked to diminished CD4 counts and do not carry adverse negative prognostic implications. ------------------------------ End of HICNet Medical News Digest V08 Issue #13 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-1165 Bitnet : ATW1H@ASUACAD