Comparison of treatments of bleeding varices: effects of differences between treatment intended and treatment received.
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Combined Modality Therapy↗
Biomedical subjects
L Rabeneck
Publications and source records attributed to L Rabeneck.
Atypical mycobacterial infection of the gastrointestinal tract in AIDS patients.
This paper will describe a case series of 35 AIDS patients with infection of the gastrointestinal (GI) tract with Mycobacterium avium-intracellulare (MAIC). Thirty-five homosexual men with a mean age of 35 yr and a mean duration of AIDS of 7.7 months prior to the diagnosis of MAIC were investigated to determine the extent of MAIC infection. The investigations included upper endoscopy, sigmoidoscopy, liver biopsy, bone marrow aspiration and biopsy, stool and blood cultures for MAIC, and D-xylose absorption tests. Tissue biopsy material was examined by light microscopy with the Ziehl-Neelsen stain. The duodenum was most commonly involved (30/34 men), with 65% positive on special stains and 76% positive on culture of biopsy tissue. Unusual fine white nodules, believed to be characteristic for duodenal MAIC infection, were observed in 12 men. Esophageal (two men), liver (two men), and rectal involvement (seven men) were found. In nine of 18 men (50%), the D-xylose test was abnormal. In 28 of 33 men (85%), blood cultures grew MAIC. Similarly, in 25 of 28 men (89%), bone marrow biopsies grew MAIC, and in 18 of 21 men (86%) stool samples grew MAIC. We conclude that GI tract infection with MAIC in AIDS patients is frequently associated with systemic infection with the agent. Duodenal involvement is common, and may be accompanied by a characteristic gross lesion, that of fine white nodules on the mucosa. Malabsorption, as determined by the D-xylose test, is not a universal finding, as has been reported previously.
Acquired Immunodeficiency Syndrome↗
Unusual esophageal ulcers containing enveloped viruslike particles in homosexual men.
Eight homosexual men presented with odynophagia. Five had a maculopapular rash and 2 had oral ulcers. Upper panendoscopy revealed the presence of multiple discrete ulcers measuring 3 mm-1.5 cm in diameter in the esophagus of each patient. The intervening mucosa appeared normal. Endoscopic brushings and biopsy specimens taken from the ulcer margins and examined by light microscopy showed no inclusion bodies or giant cells. Fungal stains were negative. Biopsy specimens examined by electron microscopy revealed enveloped virus-like particles 100-140 nm in diameter, exhibiting morphologic features consistent with retroviruses. No virus was isolated after incubation in either rhesus monkey kidney or human foreskin fibroblast culture. Serology for cytomegalovirus and herpes simplex virus was consistent with past infection. In each patient the esophageal ulcers healed completely. In summary, an illness characterized by the presence of esophageal ulcers is described in 8 homosexual men, 5 of whom also had a skin rash and 2 of whom had oral ulcers. The cause of the esophageal ulcers is likely to be the enveloped viruslike particles observed at electron microscopy.
Adult↗
Survival after necrotizing enterocolitis of leukemia treated with oral vancomycin.
A 56-yr-old female with chronic lymphocytic leukemia developed hemolytic anemia and thrombocytopenia. Prednisone therapy was instituted, but her disease was further complicated by the development of necrotizing enterocolitis. No specific enteropathogens were identified, and the stools were consistently negative for Clostridium difficile toxin. Treatment with vancomycin was instituted and resulted in complete recovery. In view of the high mortality and poor results of treatment in necrotizing enterocolitis, it is postulated that a further trial of this drug is justified.
Administration, Oral↗
Esophageal candidiasis in patients infected with the human immunodeficiency virus. A decision analysis to assess cost-effectiveness of alternative management strategies.
BACKGROUND: Currently no consensus exists concerning the timing of upper endoscopy and the choice of antifungal therapy for patients infected with the human immunodeficiency virus who also have esophageal candidiasis. The objective of this research was to determine the clinical and economic effects of alternative management strategies for these patients. METHODS: Decision analysis was used to evaluate the outcomes, costs, and cost-effectiveness of two strategies for the diagnostic workup and treatment of patients infected with the human immunodeficiency virus with dysphagia and/or odynophagia: (1) empiric--a strategy to treat all patients empirically with an oral antifungal agent for up to 4 weeks; and (2) initial esophagogastroduodenoscopy (EGD)--a strategy to perform EGD on all patients and to treat only those with esophageal candidiasis with an oral antifungal agent for up to 4 weeks. Within each strategy, three antifungal regimens were evaluated: ketoconazole, 200 mg daily; fluconazole, 100 mg daily; and ketoconazole, 200 mg daily, for 2 weeks followed by fluconazole, 200 mg daily, for 2 weeks in nonresponders. Information on the probability of esophageal candidiasis in patients with esophageal symptoms and the efficacy of antifungal therapy was obtained from the literature. The costs for diagnostic workup were estimated using both teaching hospital charges and Medicare reimbursement payments. The costs of antifungal therapy were estimated from local pharmacy charges. The average cost per complete response and incremental cost-effectiveness were calculated and subjected to sensitivity analysis. RESULTS: Using the best available evidence for antifungal efficacy, empiric fluconazole was the most cost-effective strategy for all probabilities of esophageal candidiasis that were more than 0.55. Using teaching hospital charges in our base-case analysis, the average costs per complete response for empiric fluconazole and initial EGD and fluconazole were $2706 and $3141, respectively. The incremental cost-effectiveness of initial EGD and fluconazole compared with empiric fluconazole was $3792 per additional complete response. When the cost-effectiveness of the two strategies was compared as the cost of diagnostic workup was varied, initial EGD and fluconazole became the dominant strategy when the diagnostic workup cost fell below $710, a figure that is less than the current Medicare reimbursement payment. CONCLUSIONS: From the perspective of the payer of medical care, empiric fluconazole is the most cost-effective strategy for the initial management of patients infected with the human immunodeficiency virus with esophageal symptoms.
AIDS-Related Opportunistic Infections↗
Why should gastroenterologists know about outcomes research?
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Endoscopy, Digestive System↗
A comparison of fat-free mass estimates in men infected with the human immunodeficiency virus.
BACKGROUND: Loss of lean-body mass has been found to be predictive of death from wasting in HIV-infected individuals. Several clinically applicable, noninvasive methods for estimating body wasting are available, but the comparability of these methods is not known. The objective of this study was to assess the agreement between estimates of lean-body mass in HIV-infected men. METHODS: Lean-body mass was measured by bioelectrical impedance assessment, by prediction equations that used anthropometric measurements, and by total body electrical conductivity as the comparison method in 27 outpatient HIV-infected men seen at the Houston Veterans Affairs Special Medicine Clinic. Agreement was assessed by comparing the difference between two methods (the bias) with the mean of those two methods. This statistical approach evaluates whether two methods are similar enough that measurements from one might accurately replace those of the other. RESULTS: The mean +/- SE for lean-body mass were 55.98 +/- 1.96 kg for total body electrical conductivity and 55.18 +/- 1.27 kg for bioelectrical impedance assessment; they ranged from 55.18 +/- 1.27 to 63.71 +/- 1.89 kg for the prediction equations. CONCLUSIONS: In individual subjects, no alternate method gave estimates of lean-body mass that were the same as estimates from total body electrical conductivity. One prediction equation (Brozek) gave estimates that might be useful for following changes in fat-free mass over time because the bias did not change substantially for increasing values of lean-body mass. On the other hand, because there were no statistically significant differences between the mean lean-body mass estimates by total body electrical conductivity and those measured by bioelectrical impedance assessment or a prediction equation on the basis of body mass index, the latter two methods might be useful in assessing lean-body mass in groups.
Adult↗