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Biomedical subjects

D L Cohn

Publications and source records attributed to D L Cohn.

At least 55 records · Page 3Linked to original sources
PubMed1995

Multifocal cellulitis and monoarticular arthritis as manifestations of Helicobacter cinaedi bacteremia.

Helicobacter cinaedi (formerly Campylobacter cinaedi) was first detected in the fecal flora of homosexual men. Since 1984, 11 case reports of H. cinaedi bacteremia have been published; most cases have presented as a nonspecific febrile illness in homosexual men infected with the human immunodeficiency virus (HIV). We identified seven additional cases of H. cinaedi bacteremia in two Denver hospitals within a 5-year period, which suggests that this illness is not as rare as was previously thought. Six of these cases of H. cinaedi bacteremia occurred in homosexual men who were infected with HIV. Four patients presented with the distinctive cutaneous manifestation of multifocal cellulitis, and two patients had monoarticular arthritis. Microbiological diagnosis of this infection was delayed by the slow growth of the bacterium in nonradiometric blood culture bottles. Although the patients' bacteremia was prolonged, their response to treatment was excellent. In contrast to campylobacter infections in HIV-infected patients, H. cinaedi bacteremia did not relapse after a course of effective therapy. H. cinaedi bacteremia should be suspected in HIV-infected individuals who present with an indolent febrile illness, particularly in the presence of multifocal cellulitis and/or arthritis.

AIDS-Related Opportunistic Infections↗
PubMed1994

Megestrol acetate in patients with AIDS-related cachexia.

OBJECTIVES: To compare the effects of oral suspensions of megestrol acetate, 800 mg/d, and placebo on body weight in patients with acquired immunodeficiency syndrome (AIDS)-related weight loss. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Outpatient community and university patient care setting. PATIENTS: Consecutive patients with AIDS who had substantial weight loss and anorexia were enrolled. Of 271 patients, 270 and 195 were evaluable for safety and efficacy, respectively. INTERVENTIONS: Patients were randomly assigned to receive placebo or megestrol acetate (100 mg, 400 mg, or 800 mg) daily for 12 weeks. MAIN OUTCOME MEASURES: The primary efficacy criterion was weight gain. Patients were evaluated at 4-week intervals for changes in weight and body composition, caloric intake, sense of well-being, toxic effects, and appetite. RESULTS: For evaluable patients receiving 800 mg of megestrol acetate per day, 64.2% gained 2.27 kg (5 pounds) or more compared with 21.4% of patients receiving placebo (P < 0.001). An intent-to-treat analysis showed significant differences (P = 0.002) between those receiving placebo and those receiving 800 mg of megestrol acetate for the number of patients who gained 2.27 kg (5 pounds) or more (8 of 32 [25%] compared with 38 of 61 [62.3%], respectively). Compared with patients receiving placebo at the time of maximum weight change, evaluable patients receiving megestrol acetate, 800 mg/d, reported improvement in overall well-being and had an increase in mean weight gain (-0.725 compared with 3.54 kg [-1.6 compared with +7.8 pounds]; P < 0.001), lean body mass (-0.772 compared with +1.14 kg [-1.7 compared with +2.5 pounds]; P < 0.001), appetite grade (P < 0.001), and caloric intake (-107 compared with +645.6 calories/d; P = 0.001). CONCLUSIONS: In patients with AIDS-related weight loss, megestrol acetate can stimulate appetite, food intake, and statistically significant weight gain that is associated with a patient-reported improvement in an overall sense of well-being.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Utility of paired blood cultures and smears in diagnosis of disseminated Mycobacterium avium complex infections in AIDS patients.

For 273 patients evaluated for disseminated Mycobacterium avium complex infection, a total of 1,047 mycobacterial blood cultures (MBCs) were submitted; the M. avium complex was recovered from 140 (13%) of the specimens. Results for the paired MBCs were highly concordant: in 392 of 462 (85%) culture sets, both MBCs were negative, in 53 of 462 (11%) sets, both MBCs were positive, and in only 17 of 462 (4%) sets was one culture positive and the other negative. Acid-fast smears were done on sediments from 671 specimens; smears were positive for 4 of 98 (4%) cultures that grew the M. avium complex. A single MBC should be obtained and then repeated if negative and disseminated M. avium complex infection is still clinically suspected. Use of direct acid-fast smears of sediments is not a reliable means of detecting mycobacteremia.

AIDS-Related Opportunistic Infections↗
PubMed1994

Treatment and prevention of tuberculosis in HIV-infected persons.

The treatment and prevention of tuberculosis in HIV-infected patients present significant new challenges. In patients with drug-susceptible organisms, treatment initially with three- and four-drug followed by two-drug regimens used for 6 to 9 months is efficacious, although there appears to be higher rates of adverse drug reactions than in HIV-negative patients. Treatment of MDR-TB is more difficult, requiring a high index of clinical suspicion and rapid detection and the use of multiple drugs with lower efficacy and greater toxicity than first-line agents. Directly observed therapy is the single most effective public health strategy to ensure completion of therapy and to prevent the emergence of drug-resistant tuberculosis. Isoniazid preventive therapy should be given to HIV-infected patients who are tuberculin positive and considered in selected patients who are anergic. There are many unresolved issues and future needs, including (1) the optimal regimen and duration of therapy for drug-sensitive tuberculosis; (2) the necessity for maintenance therapy following completion of a multidrug regimen; (3) an optimal regimen for treatment of MDR-TB; (4) the duration of isoniazid preventive therapy; (5) efficacy and duration of other preventive regimens, for example, pyrazinamide and rifampin; (6) the need for and choice of drugs for persons exposed to MDR-TB; (7) development of new antimycobacterial agents; and (8) the feasibility of some of these strategies in developing countries, which have the greatest burden of tuberculosis with HIV infection. Ongoing and future studies will address these questions to ultimately improve the treatment and prevention of tuberculosis in the HIV-infected patient.

Antitubercular Agents↗
PubMed1993

Two controlled trials of rifabutin prophylaxis against Mycobacterium avium complex infection in AIDS.

BACKGROUND: Disseminated Mycobacterium avium complex infection eventually develops in most patients with the acquired immunodeficiency syndrome (AIDS). This infection results in substantial morbidity and reduces survival by about six months. METHODS: We conducted two randomized, double-blind, multicenter trials of daily prophylactic treatment with either rifabutin (300 mg) or placebo. All the patients had AIDS and CD4 cell counts < or = 200 per cubic millimeter. The primary end point was M. avium complex bacteremia as assessed monthly by blood culture. The secondary end points were signs and symptoms associated with disseminated M. avium complex infection, adverse events, hospitalization, and survival. RESULTS: In the first trial, M. avium complex bacteremia developed in 51 of 298 patients (17 percent) assigned to placebo and 24 of 292 patients (8 percent) assigned to rifabutin (P < 0.001). In the second trial, bacteremia developed in 51 of 282 patients in the placebo group (18 percent) and 24 of 274 patients in the rifabutin group (9 percent) (P = 0.002). Rifabutin significantly delayed fatigue, fever, decline in the Karnofsky performance score (by > or = 20 percent), decline in the hemoglobin level (by more than 10 percent), elevation in alkaline phosphatase, and hospitalization. The incidence of adverse events was similar with rifabutin and placebo. Overall survival did not differ significantly between the two groups, although there were fewer deaths with rifabutin (33) than with placebo (47) during the double-blind phase (P = 0.086). The distribution of minimal inhibitory concentrations of rifabutin among the isolates of M. avium complex did not differ significantly between the treatment groups. CONCLUSIONS: Rifabutin, given prophylactically, reduces the frequency of disseminated M. avium complex infection in patients with AIDS and CD4 counts < or = 200 per cubic millimeter.

AIDS-Related Opportunistic Infections↗
PubMed1993

Cost of care for patients with human immunodeficiency virus infection. Patterns of utilization and charges in a public health care system.

BACKGROUND: The increasing impact of human immunodeficiency virus (HIV) infection on the health care delivery system requires surveillance of current patterns of HIV-related health care utilization to adequately plan for future needs. Most studies to date have concentrated on inpatient care for patients with the acquired immunodeficiency syndrome (AIDS). Outpatient utilization has been less well studied and there are few data regarding HIV-infected patients without a diagnosis of AIDS. METHODS: Denver Health and Hospitals is a public system delivering comprehensive health care to mostly indigent residents of the city and county of Denver. Patients with HIV infection in this system were identified through multiple surveillance sources, and billing system records for these patients were analyzed. RESULTS: During 1990, 812 patients with HIV infection of 13 years or more were accessed in the Denver Health and Hospitals. During that year, the total HIV-related health care charges were $7,858,690, of which 57% were for inpatient care and 43% for ambulatory care. Patients with AIDS (34% of patients) accounted for 62% of all charges, and patients with HIV infection but without a diagnosis of AIDS (66% of patients) for 38% of charges. Compared with national predictions, patients with AIDS in our system had lower inpatient and higher outpatient utilization. CONCLUSIONS: These results are consistent with a shift from inpatient to outpatient health care services in patients with AIDS. A significant proportion of HIV-related health care costs are incurred by patients who have not yet developed AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Results of screening for tuberculosis in foreign-born persons applying for adjustment of immigration status.

As part of the required screening process of illegal aliens applying for adjustment of status by the Immigration and Naturalization Service, 7,573 persons were evaluated for tuberculous infection by the Denver Department of Health and Hospitals from May 1987 through December 1988. Applicants were screened with tuberculin skin testing, chest radiographs, or both. Review of 6,520 charts that were available found that 4,840 applicants had tuberculin skin tests, of which 2,039 (42 percent) were > or = 10 mm and 1,528 had further evaluation at the Denver Metro Tuberculosis Clinic. Seventy-five percent of the applicants were between the ages of 15 and 34 years, and 91 percent were from Mexico. Evidence of past or current tuberculous infection on chest radiograph was present in 273 (17 percent) and 16 (7 percent) had sputum cultures obtained that identified four new cases of active tuberculosis. Isoniazid preventive therapy (IPT) was recommended to 1,029 applicants, of whom 29 (3 percent) were 35 years of age or older; 716 (70 percent) completed at least six months of treatment. We conclude that there is a high prevalence of tuberculous infection in foreign-born persons applying for adjustment of immigration status, but a low prevalence of clinically apparent tuberculosis. This population is an excellent target for IPT, which can be achieved with good success. Proactive screening and preventive therapy is likely to significantly reduce tuberculosis reactivation and morbidity, prevent secondary infection of contacts, and be cost-effective.

Adolescent↗
PubMed1993

Disseminated Mycobacterium genavense infection: clinical and microbiological features and response to therapy.

OBJECTIVE: Mycobacterium genavense is a newly described pathogen that causes disseminated infection in AIDS. It is difficult to detect and identify due to its slow growth and fastidious nature. There is little information available about therapy for this new pathogen. We describe clinical and laboratory features and response to therapy in four patients with advanced AIDS complicated by disseminated M. genavense infection from Denver, Colorado, USA. DESIGN AND METHODS: Retrospective analysis of four cases identified in an AIDS clinic affiliated with a municipal hospital in Denver, Colorado. Clinical samples were inoculated onto BACTEC 12B, Lowenstein-Jensen, and Middlebrook 7H11 media. RESULTS: The clinical features mimicked those of disseminated M. avium complex infection, with invasion of liver, spleen and lymph nodes with acid-fast bacilli (AFB). Acid-fast smears of blood and lymph nodes were positive; there was a modest increase in the growth index in BACTEC broth and tiny colonies appeared on Middlebrook agar. Patients were treated with combinations of antimycobacterial agents. Blood smears and cultures reverted to negative in treated patients. The best clinical response was associated with clarithromycin therapy. CONCLUSIONS: Disseminated disease due to M. genavense should be suspected among patients with the clinical presentation of disseminated M. avium complex infection and low growth index on BACTEC cultures for AFB. The diagnosis of M. genavense may be facilitated by performing acid-fast stains of samples from BACTEC bottles in such individuals. Clarithromycin therapy is associated with clinical improvement and clearance of bacteremia.

AIDS-Related Opportunistic Infections↗
PubMed1992

Spectrum of disease in persons with human immunodeficiency virus infection in the United States.

OBJECTIVE: To describe the spectrum of disease in persons with human immunodeficiency virus (HIV) infection. DESIGN: Retrospective survey of medical records. SETTING: More than 50 clinics, hospitals, and private medical practices in nine US cities. PATIENTS: A total of 626 women and 7008 men 13 years of age or older with HIV infection who received medical care from January 1990 through March 1991 were consecutively enrolled. MAIN OUTCOME MEASURES: Any history of diseases in the 1987 case definition for the acquired immunodeficiency syndrome (AIDS), and during the 12-month period preceding enrollment (baseline period), the occurrence of other major diseases, hospitalizations, and results of CD4+ lymphocyte counts. RESULTS: Thirty-two percent of persons met the 1987 case definition for AIDS. The occurrence of an AIDS-indicator disease during the baseline period ranged from 3% (33/1011) to 46% (1254/2748) among persons with CD4+ lymphocyte counts of 0.50 x 10(9)/L or greater and fewer than 0.20 x 10(9)/L (greater than or equal to 500 and less than 200 CD4+ lymphocytes per microliter), respectively, and, at comparable CD4+ lymphocyte levels, was similar among women compared with men, and among persons who reported intravenous drug use compared with men who reported male-to-male sex. The frequency of one or more other major infectious diseases (eg, other pneumonias, bacterial sepsis, pulmonary tuberculosis) ranged from 6% to 16% among persons with CD4+ lymphocyte counts of 0.50 x 10(9)/L or greater and fewer than 0.20 x 10(9)/L, respectively; these illnesses were also associated with a history of intravenous drug use. Among persons who did not meet the 1987 AIDS case definition, 30% of those with an available CD4+ lymphocyte count had fewer CD4+ cells than 0.20 x 10(9)/L, 8% had one or more major infectious diseases, and 14% had one or more hospital admissions. CONCLUSIONS: For every person with AIDS at these sites, two additional persons with HIV infection were receiving medical care, many of whom had severe immunosuppression and a broad spectrum of serious HIV-related disease.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Comparison of the abilities of Mycobacterium avium and Mycobacterium intracellulare to infect and multiply in cultured human macrophages from normal and human immunodeficiency virus-infected subjects.

Patients with AIDS commonly develop disseminated infections with Mycobacterium avium (MA) but not its close relative, M. intracellulare (MI). In non-AIDS patients who have these infections, the two species are about equally distributed. The higher incidence of infection with MA than with MI in AIDS patients might be due to the selective susceptibility of these patients to MA. This possibility was tested by comparing the abilities of MA and MI to infect and replicate in cultured macrophages from normal subjects and from patients with AIDS-related complex or AIDS. The macrophages were cultured in medium supplemented with 1 or 5% normal or patient sera or with 1% defined serum substitute. Replication of MA (serovar 4) or MI (serovars 16 and 17) in the macrophages was measured by CFU counts made from lysed samples of the macrophages taken at 0,4, and 7 days after macrophage infection. MA and MI in infected normal macrophages which were cultured in normal serum replicated in these macrophages at similar rates. MA but not MI multiplied abnormally rapidly in patient macrophages cultured in either normal serum or patient serum. The accelerated growth of MA in patient macrophages was macrophage dependent, because patient sera did not change the rate of MA replication in culture medium lacking macrophages. However, patient sera did increase the permissiveness of normal macrophages to MA but not MI. These results suggest that a selective increased susceptibility to MA compared with a retained normal resistance to MI in human immunodeficiency virus-infected patients as they progress from AIDS-related complex to AIDS accounts for the higher prevalence of MA than MI infection in AIDS patients. The results also indicate that the mechanisms of native resistance in human macrophages to MA and MI are different.

Adult↗
PubMed1992

Men's disclosure of HIV test results to male primary sex partners.

We evaluated disclosure of human immunodeficiency virus (HIV) antibody status to a main sex partner and the impact on the relationship in men who have sex with men and who are enrolled in the Acquired Immunodeficiency Syndrome (AIDS) Community Demonstration Projects cohorts. Eighty-nine percent of both seronegative and seropositive men disclosed the results to their main sex partner. Seventy percent of the seronegative men and 82% of the seropositive men who did so reported that the relationship remained "as strong as ever" after 6 months. Most men who did not disclose their test results to their main partner reported being "single" after 6 months.

Adult↗
PubMed1992

Comparative trial of dapsone versus trimethoprim/sulfamethoxazole for primary prophylaxis of Pneumocystis carinii pneumonia.

The purpose of this study was to compare the efficacy and safety of dapsone and trimethoprim/sulfamethoxazole in the primary prophylaxis of Pneumocystis carinii pneumonia (PCP) in patients infected with the human immunodeficiency virus (HIV) and having less than 200 CD4-positive cells per ml. This was a prospective, randomized, open-label study, using dapsone (100 mg p.o.) or trimethoprim/sulfamethoxazole (160 mg/800 mg p.o.) daily. Patients who developed toxicity requiring discontinuation were offered to cross over to the other study drug. They continued in the study until development of toxicity or documented PCP. Eighty-six patients were enrolled; 47 were randomized to receive dapsone and 39 to receive trimethoprim/sulfamethoxazole. Discontinuation of initial study drug occurred in 33 of the dapsone group and 25 of the trimethoprim/sulfamethoxazole group. Rash was the most common reason for discontinuation. Ten patients crossed over from dapsone to trimethoprim/sulfamethoxazole (4 successfully) and 11 patients crossed over from trimethoprim/sulfamethoxazole to dapsone (6 successfully). During 1,638 patient-months of observation (862 for dapsone and 776 for trimethoprim/sulfamethoxazole), one episode of PCP developed in each group. Both dapsone and trimethoprim/sulfamethoxazole are efficacious for the prophylaxis of PCP in HIV-infected persons with less than 200 CD4-positive cells per ml, but are each associated with significant toxicity. Development of toxicity to one drug does not invariably predict toxicity to the other.

Adult↗
PubMed1991

Prevalence of serum antibody to the type-specific glycopeptidolipid antigens of Mycobacterium avium in human immunodeficiency virus-positive and -negative individuals.

An enzyme-linked immunosorbent assay was constructed by using as antigens the type-specific immunodominant glycopeptidolipids of selected serotypes of Mycobacterium avium. This assay system was used to determine the prevalence of raised antibody levels to these antigens in groups of controls, human immunodeficiency (HIV)-negative and -positive homosexual men, and HIV-negative patients with active M. avium infections as a possible indicator of potential exposure and/or colonization by M. avium in these individuals. The results indicate that while antibody levels were raised in only 2.4% of control individuals, 33% of HIV-negative homosexual men and 44% of HIV-positive patients exhibited raised levels. Moreover, further examination of the HIV-positive group revealed no correlation between antiglycopeptidolipid antibody activity and helper T cell numbers. These data indicate that exposure to M. avium is prevalent among the homosexual male population, regardless of their HIV status. Moreover, the data are suggestive that the emergence of disseminated M. avium disease in HIV-positive patients may sometimes arise from earlier colonization, rather than as a newly acquired infection during terminal immunodeficiency.

Adult↗