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Biomedical subjects

J S Currier

Publications and source records attributed to J S Currier.

29 records · Page 2Linked to original sources
PubMed1997

A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. AIDS Clinical Trials Group 320 Study Team.

BACKGROUND: The efficacy and safety of adding a protease inhibitor to two nucleoside analogues to treat human immunodeficiency virus type 1 (HIV-1) infection are not clear. We compared treatment with the protease inhibitor indinavir in addition to zidovudine and lamivudine with treatment with the two nucleosides alone in HIV-infected adults previously treated with zidovudine. METHODS: A total of 1156 patients not previously treated with lamivudine or protease inhibitors were stratified according to CD4 cell count (50 or fewer vs. 51 to 200 cells per cubic millimeter) and randomly assigned to one of two daily regimens: 600 mg of zidovudine (or stavudine) and 300 mg of lamivudine, or that regimen with 2400 mg of indinavir. The primary end point was the time to the development of the acquired immunodeficiency syndrome (AIDS) or death. RESULTS: The proportion of patients whose disease progressed to AIDS or death was lower with indinavir, zidovudine, and lamivudine (6 percent) than with zidovudine and lamivudine alone (11 percent; estimated hazard ratio, 0.50; 95 percent confidence interval, 0.33 to 0.76; P=0.001). Mortality in the two groups was 1.4 percent and 3.1 percent, respectively (estimated hazard ratio, 0.43; 95 percent confidence interval, 0.19 to 0.99; P=0.04). The effects of treatment were similar in both CD4 cell strata. The responses of CD4 cells and plasma HIV-1 RNA paralleled the clinical results. CONCLUSIONS: Treatment with indinavir, zidovudine, and lamivudine as compared with zidovudine and lamivudine alone significantly slows the progression of HIV-1 disease in patients with 200 CD4 cells or fewer per cubic millimeter and prior exposure to zidovudine.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Health values of patients infected with human immunodeficiency virus. Relationship to mental health and physical functioning.

To assess the health values of patients infected with human immunodeficiency virus (HIV) and examine the relationships between their health values and health status at two points in time, the authors sought to determine whether patients' physical and mental health statuses were good predictors of how they valued their current state of health. One hundred thirty-nine patients with various stages of HIV infection were interviewed in a prospective cohort study based in a primary care practice of a community-based teaching hospital. Patients were interviewed twice at 6-month intervals using three health value measures--the time trade off, rating scale, and Quality of Well-being Scale--and three health status measures: the 18-item Mental Health Inventory, the Dyspnea-Fatigue Index, and the Medical Outcomes Study SF-36 Health Survey. The health status of HIV-infected patients was compromised and, with the exception of mental health, generally was worse among patients with more advanced HIV-infection. Rating scale and Quality of Well-being Scale scores were related inversely to disease stage, but time-trade off scores generally were higher regardless of disease stage. Health value measures showed moderate relationships with measures of physical functioning (r = 0.34-0.68) but only a fair relationship with mental health (r = 0.00-0.48). The health status of HIV-infected patients who remained asymptomatic or remained symptomatic but without developing acquired immunodeficiency syndrome (AIDS) changed little over 6 months, whereas the health status of patients with AIDS and of patients manifesting progression of HIV-infection deteriorated over time. In contrast, health values, particularly time-tradeoff scores, remained stable even in the face of changes in health status and disease progression. With the exception of mental health, the impact of HIV infection on health status tends to parallel the clinical stage of disease. Health values of HIV-infected patients, however, generally are high and correlate better with physical functioning than with mental health.

Activities of Daily Living↗
PubMed1995

Impact of clarithromycin and azithromycin on patterns of treatment and survival among AIDS patients with disseminated Mycobacterium avium complex.

OBJECTIVE: To determine the impact of the introduction of clarithromycin and azithromycin on the treatment and survival of patients with AIDS and disseminated Mycobacterium avium complex (DMAC). DESIGN: Retrospective review over a 3.5-year interval. SETTING: Tertiary-care, university teaching hospital. PATIENTS: Charts of all patients with cultures of blood or bone-marrow positive for acid-fast bacilli (n = 103) were reviewed. Data on laboratory results at the time of DMAC diagnosis, antimycobacterial therapy, antiretroviral therapy, and survival was collected. RESULTS: Prior to the availability of clarithromycin and azithromycin 61.5% of patients received antimycobacterial treatment compared with 92% afterwards (P = 0.0014). Median survival of treated patients was 255 versus 145 days for untreated patients (P < 0.001). Median survival of macrolide-treated patients was 284 versus 168 days for patients receiving treatment without a macrolide (P = 0.09). Univariate predictors of survival were antimycobacterial treatment, use of antiretrovirals, and year of diagnosis. In a multivariate model, no antimycobacterial treatment (hazard ratio, 3.83; P = 0.003) was associated with shorter survival, and treatment without a macrolide (hazard ratio, 2.29; P = 0.075) showed a trend towards shorter survival versus treatment with macrolide-containing regimens. CONCLUSIONS: The introduction of clarithromycin and azithromycin has been associated with an increase in the proportion of patients with DMAC receiving treatment and with increased survival of these patients.

AIDS-Related Opportunistic Infections↗
PubMed1993

Cefazolin compared with cefoxitin for cesarean section prophylaxis: the use of a two-stage study design.

The authors used a two-stage design to compare the risk of endometritis in women undergoing non-elective cesarean section who received cefazolin prophylaxis (n = 481) with those who received cefoxitin prophylaxis (n = 1799). The primary data source for this study was an automated record linkage system which allowed the ascertainment of exposure(antibiotic prophylaxis) and preliminary ascertainment of outcome (post-partum endometritis) on a consecutive sample of women undergoing cesarean section between 1 April 1987 and 30 September 1989. Potentially important covariates not available in the automated data source were sampled by review of complete medical records of a random sample of each exposure-disease category of the cohort. Of the 2280 women studied, 99 (4.3%) developed postpartum endometritis. After control for age, race, anemia, presence of ruptured membranes, parity, labor, number of vaginal examinations and payor status the adjusted odds ratio for cefazolin compared to cefoxitin was 0.95 (95% C.I. 0.5-1.9). The cost of prophylaxis was significantly higher for women who received cefoxitin prophylaxis ($56/patient vs $9.55/patient). These results suggest that cefazolin prophylaxis should be favored over cefoxitin due to lower cost and similar efficacy. This study also demonstrates the efficiency of a two-stage design in the setting where exposure and outcome are available for an entire cohort but information about important covariates is more difficult to obtain.

Adult↗
PubMed1993

Electronic surveillance of antibiotic exposure and coded discharge diagnoses as indicators of postoperative infection and other quality assurance measures.

OBJECTIVES: To assess postoperative exposure to parenteral antibiotics and coded discharge diagnoses of infection as markers of nosocomial infection, postoperative morbidity, and potentially inappropriate antibiotic use after cesarean section. DESIGN: Retrospective cohort study to compare automated markers with the criterion of record review. SETTING: Tertiary care hospital. PATIENTS: Women admitted to a large teaching hospital after April 15, 1987, and discharged before October 1, 1989, who underwent a nonrepeat, nonelective cesarean section and had received prophylaxis with a cephalosporin. METHODS: Antibiotic exposure and discharge diagnosis codes were obtained from a large electronic hospital data base. A sample of charts was reviewed to determine the presence of infection, other postoperative complications, and postoperative antibiotic exposure. RESULTS: A total of 2,197 women who had undergone a nonrepeat nonelective cesarean section were included in the study cohort. These women were assigned to 6 subgroups based on postoperative antibiotic exposure status and discharge codes suggesting endometritis, other postoperative infection, or no infection. Review of 457 records indicated that the overall infection rate was 9%. Eight percent of all the patients had a coded diagnosis for infection, and 16% received some parenteral antibiotics after the first postoperative day. Exposure to at least 2 days of parenteral postoperative antibiotics was the best marker by which to discriminate between infected and uninfected patients, with a sensitivity of 81%, a specificity of 95%, and a positive predictive value of 61% for detecting infection. The corresponding figures for coded diagnoses for infection had rates of 65%, 97%, and 74%, respectively. The combination of discharge codes and exposure to parenteral postoperative antibiotics resulted in a more accurate but less sensitive marker for nosocomial infections, with a positive predictive value of 94% and a sensitivity of 59%. The groups with discordant parenteral postoperative antibiotics exposure and discharge codes for infection were enriched for errors in coding, noninfectious morbidity, and unexplained antibiotic use. Less than 1% of the entire cohort had > or = to 2 days of parenteral postoperative antibiotics without any reason apparent in the medical record. CONCLUSIONS: Parenteral postoperative antibiotic exposure determined from automated pharmacy records correlated with the results of the more labor-intensive manual review of medical records for the identification of nosocomial infection. In addition, information on antibiotic exposure combined with coded discharge diagnoses provided a rapid screen to identify subgroups of patients with higher rates of infectious and noninfectious morbidity, unexplained antibiotic use, and errors in discharge coding. Information derived from electronic data bases created for administrative purposes may be useful as a marker for infectious complications, inappropriate antibiotic prescribing, and other issues related to total quality hospital monitoring.

Adult↗
PubMedDate not supplied

The safety of discontinuation of maintenance therapy for cytomegalovirus (CMV) retinitis and incidence of immune recovery uveitis following potent antiretroviral therapy.

BACKGROUND: Reconstitution of immune function during potent antiretroviral therapy can prompt discontinuation of maintenance cytomegalovirus (CMV) therapy but has also been associated with sight-threatening inflammatory conditions including immune recovery uveitis (IRU). METHOD: Patients with inactive CMV retinitis and a CD4+ cell count above 100/mm3, receiving CMV therapy and stable combination antiretroviral therapy, were assigned to one of two groups based on willingness to discontinue CMV therapy. RESULTS: Thirty-eight participants were enrolled: 28 discontinued anti-CMV therapy (Group 1) and 10 continued CMV treatment (Group 2). Median on-study follow-up was 16 months. One Group 1 participant who experienced an increase in plasma HIV viral load and a decline in CD4+ cell count developed confirmed progression of CMV retinitis. Progression or reactivation CMV retinitis was not observed among Group 2. IRU was present at study entry in 3 participants. Six participants in Group 1 and 3 participants in Group 2 developed IRU on-study. CMV viremia was not detected in any participants, and urinary shedding of CMV was intermittent. CONCLUSION: Recurrence of CMV retinitis following discontinuation of anti-CMV therapy among patients with antiretroviral-induced increases in CD4+ cell count was rare. However, IRU was common in both those who maintained and discontinued anti-CMV therapy.

Adult↗
PubMedDate not supplied

Perioperative antimicrobial prophylaxis in middle Tennessee, 1989-1990.

The patterns of use of perioperative antimicrobial prophylaxis were assessed in a randomly selected sample of short-stay hospitals in middle Tennessee. Overall, 438 procedures (48%) were associated with antimicrobial prophylaxis. Prophylaxis was more common in hospitals with more than 400 beds than in smaller hospitals. Moreover, prophylactic antibiotics were given more often for procedures with a proven indication for prophylaxis than for those without a proven indication (60% vs. 41%, P less than .05); this relationship remained constant regardless of hospital size (common odds ratio, 2.09). However, prophylaxis for procedures with a proven indication was more likely to be given in teaching hospitals than in nonteaching hospitals (odds ratios, 5.41 vs. 1.94). The duration of prophylaxis was less than 2 days for 89% of procedures. A wide variety of agents were used. This study suggests that while improvements have been made over the past decade in decisions about the duration of prophylaxis, considerable variation remains in the selection of the procedures in which such treatment is administered and of the antimicrobial agents used.

Anti-Infective Agents↗