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Biomedical subjects

A T Pavia

Publications and source records attributed to A T Pavia.

At least 37 records · Page 2Linked to original sources
PubMed1994

Didanosine compared with continuation of zidovudine in HIV-infected patients with signs of clinical deterioration while receiving zidovudine. A randomized, double-blind clinical trial. The Bristol-Myers Squibb AI454-010 Study Group.

OBJECTIVE: To determine the benefits of switching to didanosine compared with continuing zidovudine among patients infected with human immunodeficiency virus (HIV) who have previously used zidovudine and have signs of clinical deterioration. DESIGN: Randomized, double-blind, two-armed, parallel, comparative clinical trial with a blinded, compassionate crossover provision at 12 weeks. SETTING: Outpatient clinics at 19 tertiary care medical centers. PATIENTS: 312 patients infected with HIV who had received zidovudine for 6 months or more, had CD4 cell counts of 300/mm3 or less, and had signs of clinical deterioration within 12 weeks before study entry. INTERVENTION: Peroral didanosine tablets (600 mg/d adjusted for weight, "high dose") or zidovudine capsules (600 mg/d). MEASUREMENTS: Primary study end points were death, a new acquired immunodeficiency syndrome (AIDS)--defining event, or the combination of two new or recurrent HIV-related diagnoses with a 50% decrease in CD4 cells. RESULTS: Switching to didanosine was associated with fewer end points than continuing zidovudine (relative risk [RR] for zidovudine:didanosine = 1.5; 95% Cl, 1.1 to 2.0). This benefit was consistent across subgroups of patients with either AIDS-related complex or AIDS and was most apparent among those with a CD4 count at entry of 100/mm3 or more (RR = 2.2; Cl, 1.1 to 4.4). CONCLUSIONS: This study shows a positive treatment effect for switching from zidovudine to didanosine among patients with either AIDS-related complex or AIDS and validates the common practice of using clinical signs or a decrease in the CD4 count as an indication for changing therapy.

AIDS-Related Complex↗
PubMed1994

The prophylactic use of low-dose amphotericin B in bone marrow transplant patients.

PURPOSE: To evaluate the efficacy of prophylactic low-dose amphotericin B (0.1 mg/kg per day) (LDA) in preventing fungal infections in patients who have had a bone marrow transplant (BMT). MATERIALS AND METHODS: Double-blind, randomized, controlled trial in which patients undergoing bone marrow transplantation received intravenous LDA or similar-appearing placebo from the onset of neutropenia until the absolute neutrophil count remained > 0.5 x 10(9)/L, or until high-dose amphotericin B was initiated. Weekly surveillance cultures were obtained from all patients. RESULTS: Five of 18 patients (28%) randomized to placebo developed documented systemic fungal infections within the first 30 days after transplantation, compared to none of 17 patients who received LDA (P = 0.045). LDA recipients received fewer days of high-dose amphotericin B (P = 0.04) and fewer days of antibiotics (P = 0.008). There were trends towards fewer days of hospitalization (P = 0.14) and improved survival (P = 0.08); these differences were statistically significant among recipients of allogeneic BMT. No adverse effects occurred with LDA therapy. CONCLUSIONS: LDA appears to be safe and to reduce early systemic fungal infections in BMT recipients. Improved survival was observed among LDA recipients, but this was not directly attributable to the prevention of fungal infection.

Adolescent↗
PubMed1994

Invasive sinonasal disease due to Scopulariopsis candida: case report and review of scopulariopsosis.

Sinonasal infection with fungi of the order Mucorales--termed mucormycosis or zygomycosis--is sometimes seen in immunosuppressed patients, including those with diabetic ketoacidosis and malignancy. We describe a case of invasive sinonasal infection with Scopulariopsis candida (not among the Mucorales organisms) in a 12-year-old girl who was being treated for non-Hodgkin's lymphoma. Only a few cases of invasive infection with Scopulariopsis species have been reported previously; five of six of these cases were associated with persistent or fatal disease. Our patient survived without undergoing radical surgical debridement and was treated with granulocyte colony-stimulating factor, amphotericin B, and itraconazole; chemotherapy was stopped. In vitro susceptibility testing of our patient's Scopulariopsis isolate showed that it was resistant to amphotericin B and that it was relatively susceptible to itraconazole and miconazole. The case described herein demonstrates the expanding spectrum of fungal organisms that may cause invasive sinonasal infection in immunocompromised hosts and the need for reliable antifungal susceptibility testing.

Amphotericin B↗
PubMed1994

A 20-year population-based study of postdiarrheal hemolytic uremic syndrome in Utah.

OBJECTIVE: To determine epidemiologic features, trends in frequency, and predictors of clinical outcome of postdiarrheal hemolytic uremic syndrome (HUS) in Utah. DESIGN: A 20-year population-based study of HUS with a review of the HUS registry, hospital records, transplant registry, and a survey of pediatricians and pediatric nephrologists to ensure completeness of ascertainment. POPULATION: All Utah residents under 18 years of age with HUS occurring after a diarrheal prodrome between 1971 and 1990. OUTCOME MEASURES: Incidence of HUS, severity, complications, and long-term sequelae. RESULTS: There were 157 cases during 20 years; 140 (89%) occurred after a diarrheal prodrome. The mean annual incidence was 1.42/100,000 children (range 0.2 to 3.4/100,000 children/year). Periods of high incidence occurred; however, there was no overall sustained increase in incidence. Escherichia coli O157:H7 was isolated from the stool of 62% of children who had specimens submitted. There were no differences between the first and second decade in the proportion with diarrheal prodrome, bloody diarrhea, most abnormal laboratory values, hospital course, or outcome. However, admission laboratory abnormalities were more severe during the first decade suggesting a delay in diagnosis. Age < 2 years, anuria before admission, and higher white blood cell counts on admission predicted severe disease. Bad outcome (death, end-stage renal disease, or stroke) occurred in 11%; 5% died. Chronic renal sequelae, usually mild, were found on follow-up (median 6.5 years) in 51% of survivors. CONCLUSIONS: HUS has been an important clinical and public health problem in Utah for 20 years. The consistency of the clinical and epidemiologic features over 2 decades suggests that a common etiologic agent has accounted for most cases of HUS in this region since 1971.

Adolescent↗
PubMed1993

Partner notification for control of HIV: results after 2 years of a statewide program in Utah.

OBJECTIVES: We sought to evaluate the utility of partner notification for control of human immunodeficiency virus (HIV) infection and to identify subgroups in which it may be most effective. METHODS: All persons reported to be HIV-positive during a 2-year period were interviewed. Outcome measures included proportion of index patients cooperating; number of partners named, located, counseled, and tested; number of persons newly testing positive; and costs. RESULTS: Of 308 index patients, 244 (79%) cooperated. They named 890 partners; 499 (70%) of in-state partners were located. Of these, 154 (34%) had previously tested HIV-positive. Of 279 partners tested for the first time, 39 (14%) were HIV-positive. Injecting drug users were significantly more likely to cooperate than persons in other risk groups (93% vs 76%) and named more partners (median 4 vs 1). Women and persons choosing confidential testing were more likely to cooperate and named more partners. The estimated cost of the program was $62,500 per year. CONCLUSIONS: Partner notification identified a group with a high seroprevalence of HIV. It was not successful among populations that may be difficult to reach with other interventions.

AIDS Serodiagnosis↗
PubMed1992

Diarrhea among African children born to human immunodeficiency virus 1-infected mothers: clinical, microbiologic and epidemiologic features.

Diarrhea and weight loss are common features of pediatric and adult human immunodeficiency type 1 (HIV-1) infection, particularly in developing countries. We studied prospectively episodes of diarrhea in 559 children, ages 10 to 15 months, participating in a longitudinal study of perinatal HIV-1 infection in Kinshasa, Zaire. Children with HIV-1 infection had more frequent episodes of diarrhea and were more likely to present with fever or moderate or severe dehydration and to have persistent or fatal diarrhea. Of 9 HIV-1-positive infants with diarrhea, 3 had enteroadherence factor-positive Escherichia coli, compared with 5 of 74 HIV-1-negative children with diarrhea (P = 0.04); no other pathogen was associated with HIV-1 infection. In a logistic regression model diarrhea was significantly associated with HIV-1 infection in the child, moderate or severe malnutrition and symptoms of acquired immunodeficiency syndrome in the mother. Diarrhea among children with perinatal HIV infection in Zaire is more severe than among uninfected children and is associated with malnutrition and advanced disease in the mother.

Cohort Studies↗
PubMed1991

A new look at typhoid vaccination. Information for the practicing physician.

Most cases of typhoid fever in the United States occur in international travelers, with the greatest risk associated with travel to Peru, India, Pakistan, and Chile. Laboratory workers and household contacts of long-term carriers are also at greater risk than the general population. Decisions to the use typhoid vaccine involve weighing the risk of illness against the risk of vaccine reactions. Until recently, the only typhoid vaccine commercially available to US civilians was a heat-phenol-inactivated parenteral product that is 51% to 77% effective in preventing typhoid fever but frequently produces local pain and swelling, fever, headache, and malaise. A new orally administered, live-attenuated vaccine, made from the Ty21a strain of Salmonella typhi, has been recently licensed in the United States. This vaccine provides equivalent protection with a much lower incidence of adverse reactions. It is administered in a four-dose series given over 7 days. Since neither vaccine offers total protection, the most important elements in prevention of typhoid fever remain sound biosafety precautions in laboratory workers and care in selecting food and beverages by those traveling to areas where typhoid fever is endemic.

Capsules↗
PubMed1990

Hemolytic-uremic syndrome during an outbreak of Escherichia coli O157:H7 infections in institutions for mentally retarded persons: clinical and epidemiologic observations.

PURPOSE: To describe an outbreak of Escherichia coli O175:H7 infection resulting in a high rate of progression to hemolytic-uremic syndrome, and to attempt to identify predictors of and risk factors for progression. DESIGN: Case-control study among employees and comparison of daily clinical features in two groups: infected residents with subsequent development of HUS and those who had no complications. SETTING: Two institutions for retarded persons in Utah. PATIENTS: Twenty residents with E. coli O157:H7 infection (13 culture confirmed, 2 probable, and 5 possible); HUS developed in 8, and 4 died. Thirty-one infected employees (3 with culture-confirmed, 6 with probable, and 22 with possible infection). MEASUREMENTS AND MAIN RESULTS: In a case-control study among employees, infection was independently associated with eating ground beef from a single lot prepared at several barbecues and with close contact with a resident who had diarrhea. Five of eight residents in whom HUS developed had received trimethoprim-sulfamethoxazole, compared with none of seven who had no subsequent complications (p = 0.026); this finding may reflect antimicrobial treatment of patients with more severe illness. Compared with infected residents without complications, persons with HUS were younger (median age 13 vs 27 years, p = 0.043) and, by the third day of illness, had higher leukocyte counts (median 23.7 X 10(9)/L vs 9.1 X 10(9)/L, p = 0.018) and temperature (median 38.5 degrees C vs 37.0 degrees C, p = 0.016). Leukocytosis peaked on day 4, more than 24 hours before signs of HUS appeared. CONCLUSIONS: Food-borne outbreaks of E. coli O157:H7 in institutions may have devastating effects. Leukocytosis and fever may precede and predict HUS in patients with E. coli O157:H7 infection.

Adolescent↗
PubMed1990

Epidemiologic evidence that prior antimicrobial exposure decreases resistance to infection by antimicrobial-sensitive Salmonella.

Exposure to antimicrobials is known to increase the risk of infection with antimicrobial-resistant strains of Salmonella, but this effect has not been previously demonstrated with antimicrobial-sensitive strains. The effect of prior antimicrobial exposure was studied during a multistate outbreak of salmonellosis caused by an antimicrobial-sensitive strain of Salmonella havana: 19 (26%) of 72 persons infected had taken an antimicrobial within 30 days before onset of symptoms. Antimicrobial therapy was begun a mean of 15.9 days before and stopped a mean of 7.9 days before onset. In a case-control study, 11 (31%) of 35 case-patients had taken antimicrobials within 30 days of onset compared with 9 (13%) of 70 age- and neighborhood-matched controls (matched odds ratio, 4.3; 95% confidence interval, 1.3, 13.5). The association remained when controlled for the presence of underlying illness or immunosuppression. Prior antimicrobial exposure appears to increase the risk of infection with antimicrobial-sensitive and resistant strains of Salmonella. The delay between antimicrobial use and onset of symptoms suggests that the effect may be due to prolonged alteration of the colonic bacterial flora, resulting in decreased resistance to colonization.

Adolescent↗
PubMed1990

A community-wide outbreak of hepatitis A in a religious community: impact of mass administration of immune globulin.

Community-wide outbreaks of hepatitis A are frequently prolonged and difficult to control. An extensive outbreak of hepatitis A in a religious community provided an opportunity to assess the effect of mass administration of immune globulin on the course of the outbreak. Between July 1, 1988 and May 30, 1989, 204 cases occurred among 3,500 residents (58/1,000), with persons aged 5-19 years having the highest attack rate. It was found that 89% of persons older than age 19, but no persons under age 20, had evidence of prior hepatitis A infection. During a 5-day campaign, immune globulin (0.02 ml/kg) was administered to 2,287 (65%) of the 3,500 residents. The cost of vaccine and syringes was less than $3,500. New cases among immune globulin recipients virtually stopped 2 weeks after the campaign, and the incidence of hepatitis in the community decreased from 9.6/week to 1.9/week. Among persons younger than age 20 years, the efficacy of immune globulin was 88.9% (95% confidence interval 77.9-94.5) for seven months. Although the authors cannot be sure that the outbreak will not recur, they believe that mass administration of immune globulin appears to have been partially effective at controlling this community-wide outbreak.

Adolescent↗
PubMed1989

Cholera in Louisiana. Widening spectrum of seafood vehicles.

The largest cholera outbreak in the United States in over a century occurred in Louisiana from August through October 1986. Eighteen persons in 12 family clusters had stool culture or serologic evidence of infection with toxigenic Vibrio cholerae 0-group 1. Thirteen of these persons had severe diarrhea, and 4 required intensive care unit treatment. Although all 18 survived, 1 96-year-old woman with suspected cholera died shortly after hospital admission. A case-control study showed that case-patients were more likely than neighborhood control subjects to have eaten cooked crabs or cooked or raw shrimp during the week before illness. Case-patients who ate crabs were more likely than control subjects who ate crabs to have undercooked and mishandled the crabs after cooking. A third vehicle from the Gulf waters, raw oysters, caused V cholerae 01 infection in two persons residing in Florida and Georgia. All three seafood vehicles came from multiple sources. Stool isolates from the Louisiana case-patients were genetically identical to other North American strains isolated since 1973, but differ from African and Asian isolates. While crabs are the most important vehicle for V cholerae 01 infection in the United States, shrimp and oysters from the Gulf coast can also be vehicles of transmission. A persisting reservoir of V cholerae 01 along the Gulf coast may continue to cause sporadic cases and outbreaks of cholera in Gulf states and in states importing Gulf seafood.

Adult↗
PubMed1987

Sex hormones and coronary artery disease.

Previous investigators have found an increased risk of coronary heart disease in men with high levels of circulating estrogens. To elucidate further this relationship, a case-control study of atherosclerotic coronary artery disease (ASCAD) and sex hormones was undertaken in male patients. Hormone levels in men with severe ASCAD documented at angiography were compared with those in men found to be virtually free from disease and with those in a group of control subjects without signs or symptoms of ASCAD. Significantly lower total testosterone levels were observed among men with severe ASCAD compared with either control group; the free testosterone level was significantly lower than in angiographically disease-free control subjects. The same pattern of hormone levels persisted after control of covariates. Epidemiologic analysis demonstrated a fivefold decrease in risk for severe ASCAD between the lowest and the highest quartile of total testosterone. No overall pattern of association was seen between ASCAD and free or total estrogens.

Adult↗