Effect of Tai Chi in adults with rheumatoid arthritis.
Explore the source record for details and available documents.
Adult↗
Biomedical subjects
P L Hibberd
Publications and source records attributed to P L Hibberd.
Web sites with misinformation about illicit drugs.
Explore the source record for details and available documents.
Adolescent↗
Child hospitalization: an opportunity for parental smoking intervention.
BACKGROUND: Hospitalization with tobacco-related illness increases smokers' interest in cessation. Because parental smoking increases the child's risk of developing respiratory and other illnesses, a child's hospitalization might motivate a smoking parent to consider changing smoking behavior. It is unclear if parents would be receptive to smoking-cessation interventions at the time when their child is hospitalized. METHODS: In March 1999, parents of 298 consecutive children admitted to the medical services at Children's Hospital Boston were interviewed to determine the smoking status of household members. Smoking parents were invited to complete a 35-item questionnaire regarding personal smoking history and acceptability of three types of cessation interventions. RESULTS: Sixty-five smoking parents were identified among the 298 admissions; 62 of 65 (95%) participated in the survey. Among respondents, only 15% had ever participated in any smoking-cessation program, and only 31% had ever used a medication to try to quit. Although 78% of parents were willing to speak with a counselor about their smoking while their child was in the hospital, and 74% would enroll in a telephone-based smoking-cessation program, only 26% were interested in a free program requiring travel back to the hospital. All parents believed that pediatricians should offer parental smokers the chance to participate in a smoking-cessation program. CONCLUSIONS: At the time of a child's hospitalization, parents are willing to enroll in smoking interventions that include in-hospital and telephone counseling but not to travel back to the hospital. A child's hospitalization may provide a unique opportunity to enroll parents who smoke into cessation programs.
Adult↗
Vaccines for transplant recipients.
Immune dysregulation and immunosuppression regimens impact on the ability of transplant recipients to respond to immunizations. The distinct challenges of immunizations to benefit stem cell transplant recipients and solid organ transplant recipients are discussed separately. Recommended vaccines for stem cell transplant recipients and solid organ transplant candidates are suggested. New approaches to consider to enhance immune responses of transplant recipients are discussed.
Adult↗
Limulus amebocyte lysate assay for detection of endotoxin in patients with sepsis syndrome. AMCC Sepsis Project Working Group.
Clinical predictions alone are insufficiently accurate to identify patients with specific types of bloodstream infection; laboratory assays might improve such predictions. Therefore, we performed a prospective cohort study of 356 episodes of sepsis syndrome and did Limulus amebocyte lysate (LAL) assays for endotoxin. The main outcome measures were bacteremia and infection due to gram-negative organisms; other types of infection were secondary outcomes. Assays were defined as positive if the result was > or = 0.4 enzyme-linked immunosorbent assay units per milliliter. There were positive assays in 119 (33%) of 356 episodes. Assay positivity correlated with the presence of fungal bloodstream infection (P < .003) but correlated negatively with the presence of gram-negative organisms in the bloodstream (P = .04). A trend toward higher rates of mortality in the LAL assay-positive episodes was no longer present after adjusting for severity. Thus, results of LAL assay did not correlate with the presence of bacteremia due to gram-negative organisms or with mortality after adjusting for severity but did correlate with the presence of fungal bloodstream infection.
Bacteremia↗
The epidemiology of resistance to ofloxacin and oxacillin among clinical coagulase-negative staphylococcal isolates: analysis of risk factors and strain types.
Coagulase-negative staphylococci are important nosocomial pathogens that increasingly are resistant to oxacillin and fluoroquinolones. To determine predictors of acquisition of oxacillin and ofloxacin resistance, we prospectively identified 150 patients from whose clinical specimens coagulase-negative staphylococci were isolated that differed in susceptibility to oxacillin and ofloxacin. In multivariate analysis, isolation of ofloxacin-resistant coagulase-negative staphylococci was associated with receipt of aminoglycosides (odds ratio [OR] = 8.45; 95% confidence interval [CI] = 2.10-34.1; P = .001) and fluoroquinolones (OR = 11.50; 95% CI = 4.15-31.6; P < .001) within 30 days; oxacillin resistance was associated with prior receipt of beta-lactam agents (OR = 5.99; 95% CI = 2.91-12.3; P < .001). Among oxacillin-resistant strains, there was heterogeneity of pulsed-field gel electrophoresis (PFGE) types, and no type was common between ofloxacin-resistant and ofloxacin-susceptible strains. Thus ofloxacin resistance may have emerged de novo among diverse oxacillin-resistant strains following the selection pressures of antimicrobial therapy. In contrast, 50% of patients with oxacillin-susceptible/ofloxacin-resistant strains had one of two PFGE types, a finding suggesting that person-to-person transmission resulted in the dissemination of some of these strains.
Anti-Infective Agents↗
Staphylococcus aureus prosthetic valve endocarditis: optimal management and risk factors for death.
The mortality rate associated with Staphylococcus aureus prosthetic valve endocarditis (PVE) remains high. To identify clinical events associated with an increased risk of death among patients with S. aureus PVE and to evaluate the role of valve replacement surgery in reducing mortality, we conducted a retrospective cohort study of patients who met strict criteria for definite S. aureus PVE. The primary endpoint for the study was survival at 3 months from the date of diagnosis. S. aureus PVE was diagnosed in 33 patients. Of these, 14 (42%) died within 90 days of the diagnosis. Cardiac complications were detected in 22 (67%), and central nervous system (CNS) complications were detected in 11 (33%). A stepwise logistic regression multivariate model demonstrated that cardiac complications, but not CNS complications, were associated with increased mortality and that performing valve replacement surgery during antibiotic therapy was associated with decreased mortality. These associations were confirmed by using a Cox proportional hazards model with time-dependent covariates to control for survival bias. Performing valve replacement surgery during antimicrobial therapy will reduce the mortality among patients with S. aureus PVE, even those without evidence of cardiac complications.
Adult↗
Epidemiology of sepsis syndrome in 8 academic medical centers.
CONTEXT: Sepsis syndrome is a leading cause of mortality in hospitalized patients. However, few studies have described the epidemiology of sepsis syndrome in a hospitalwide population. OBJECTIVE: To describe the epidemiology of sepsis syndrome in the tertiary care hospital setting. DESIGN: Prospective, multi-institutional, observational study including 5-month follow-up. SETTING: Eight academic tertiary care centers. METHODS: Each center monitored a weighted random sample of intensive care unit (ICU) patients, non-ICU patients who had blood cultures drawn, and all patients who received a novel therapeutic agent or who died in an emergency department or ICU. Sepsis syndrome was defined as the presence of either a positive blood culture or the combination of fever, tachypnea, tachycardia, clinically suspected infection, and any 1 of 7 confirmatory criteria. Estimates of total cases expected annually were extrapolated from the number of cases, the period of observation, and the sampling fraction. RESULTS: From January 4, 1993, to April 2, 1994, 12759 patients were monitored and 1342 episodes of sepsis syndrome were documented. The extrapolated, weighted estimate of hospitalwide incidence (mean+/-95% confidence limit) of sepsis syndrome was 2.0+/-0.16 cases per 100 admissions, or 2.8+/-0.17 per 1000 patient-days. The unadjusted attack rate for sepsis syndrome between individual centers differed by as much as 3-fold, but after adjustment for institutional differences in organ transplant populations, variation from the expected number of cases was reduced to 2-fold and was not statistically significant overall. Patients in ICUs accounted for 59% of total extrapolated cases, non-ICU patients with positive blood cultures for 11%, and non-ICU patients with negative blood cultures for 30%. Septic shock was present at onset of sepsis syndrome in 25% of patients. Bloodstream infection was documented in 28%, with gram-positive organisms being the most frequent isolates. Mortality was 34% at 28 days and 45% at 5 months. CONCLUSIONS: Sepsis syndrome is common in academic hospitals, although the overall rates vary considerably with the patient population. A substantial fraction of cases occur outside ICUs. An understanding of the hospitalwide epidemiology of sepsis syndrome is vital for rational planning and treatment of hospitalized patients with sepsis syndrome, especially as new and expensive therapeutic agents become available.
Adult↗
Predicting bacteremia in patients with sepsis syndrome. Academic Medical Center Consortium Sepsis Project Working Group.
The goal of this study was to develop and validate clinical prediction rules for bacteremia and subtypes of bacteremia in patients with sepsis syndrome. Thus, a prospective cohort study, including a stratified random sample of 1342 episodes of sepsis syndrome, was done in eight academic tertiary care hospitals. The derivation set included 881 episodes, and the validation set included 461. Main outcome measures were bacteremia caused by any organism, gram-negative rods, gram-positive cocci, and fungal bloodstream infection. The spread in probability between low- and high-risk groups in the derivation sets was from 14.5% to 60.6% for bacteremia of any type, from 9.8% to 32.8% for gram-positive bacteremia, from 5.3% to 41.9% for gram-negative bacteremia, and from 0.6% to 26.1% for fungemia. Because the model for gram-positive bacteremia performed poorly, a model predicting Staphylococcus aureus bacteremia was developed; it performed better, with a low- to high-risk spread of from 2.6% to 21.0%. The prediction models allow stratification of patients according to risk of bloodstream infections; their clinical utility remains to be demonstrated.
Adult↗
Emergence and dissemination of a highly vancomycin-resistant vanA strain of Enterococcus faecium at a large teaching hospital.
We prospectively identified patients at the Massachusetts General Hospital from whom vancomycin-resistant enterococci (VRE) were isolated from a clinical specimen from 1 January 1991 through 31 December 1995. VRE strains were available from 139 (82%) of the 169 patients with clinical cases. Of these, 39 (28%) were identical or closely related by pulsed-field gel electrophoresis (i.e., VRE type A strain), including 38 (43%) of 89 VRE strains in 1995. By multivariate analysis, acquisition of the VRE type A strain was associated with receipt of clindamycin (odds ratio [OR] = 10.5), 15 or more days of hospitalization before the first isolation of VRE (OR = 2.9), and residence on one of the general medical floors (OR = 7.8). The VRE type A strain was a vanA strain of Enterococcus faecium and was highly resistant to all antimicrobial agents tested except chloramphenicol. These findings document the rapid dissemination of a highly resistant strain of E. faecium among patients and among other extant VRE strains at the Massachusetts General Hospital in 1995.
Adolescent↗
Burkholderia cepacia respiratory tract acquisition: epidemiology and molecular characterization of a large nosocomial outbreak.
In 1994 we investigated a large outbreak of Burkholderia (formerly Pseudomonas) cepacia respiratory tract acquisition. A case patient was defined as any patient with at least one sputum culture from which B. cepacia was isolated from 1 January to 31 December 1994. Seventy cases were identified. Most (40 [61%]) occurred between 1 February and 31 March 1994; of these, 35 (86%) were mechanically ventilated patients, 30 of whom were in an intensive-care unit (ICU) when B. cepacia was first isolated. Compared with control patients who were mechanically ventilated in an ICU, these 30 case-patients were significantly more likely to have been ventilated for 2 or more days (30/30 v. 15/30; P < 0.001) or to have been intubated more than once (12/30 v. 2/30; OR = 9.3, 95% CI 1.6-68.8; P = 0.002) before the first isolation of B. cepacia. By multivariate analysis, the 35 mechanically ventilated case-patients were significantly more likely to have received a nebulized medication (OR = 11.9, 95% CI = 1.6-553.1; P < 0.001) and a cephalosporin antimicrobial (OR = 11.9, 95% CI = 1.6-553.1) in the 10 days before the first isolation of B. cepacia, compared with B. cepacia-negative control-patients matched by date and duration of most recent mechanical ventilation. Although B. cepacia was not cultured from medications or the hospital environment, all outbreak strains tested had an identical DNA restriction endonuclease digestion pattern by pulsed-field gel electrophoresis. Review of respiratory therapy procedures revealed opportunities for contamination of nebulizer reservoirs. This investigation suggests that careful adherence to standard procedures for administration of nebulized medications is essential to prevent nosocomial respiratory infections.
Adolescent↗
Preemptive ganciclovir therapy to prevent cytomegalovirus disease in cytomegalovirus antibody-positive renal transplant recipients. A randomized controlled trial.
OBJECTIVE: To determine whether preemptive ganciclovir therapy administered daily during antilymphocyte antibody therapy can prevent cytomegalovirus disease in renal transplant recipients who are positive for cytomegalovirus antibody. DESIGN: Randomized, controlled, multicenter trial. SETTING: 6 university-affiliated transplantation centers. PATIENTS: 113 renal transplant recipients who were positive for cytomegalovirus antibody. INTERVENTION: Patients were randomly assigned to receive either 1) ganciclovir, 2.5 mg/kg body weight administered intravenously on every day that antilymphocyte antibody therapy was administered or 2) no anticytomegalovirus therapy. MEASUREMENTS: Patients were observed for 6 months after completion of antilymphocyte antibody therapy for development of cytomegalovirus disease and cytomegalovirus viremia. RESULTS: Cytomegalovirus disease occurred in 14% of patients (9 of 64) who received preemptive ganciclovir therapy and in 33% of controls (16 of 49) (P = 0.018). Cytomegalovirus was isolated from buffy-coat specimens from 17% of patients (11 of 64) receiving preemptive ganciclovir and from 35% of controls (17 of 49) (P = 0.03). Controlling for the reason (induction or treatment of rejection) for using antilymphocyte antibodies in a Cox proportional hazards model, we found that preemptive ganciclovir still protected against cytomegalovirus disease (adjusted relative risk, 0.27; 95% CI, 0.12 to 0.64). No adverse events were attributed to preemptive ganciclovir therapy during or within 6 months of its administration. CONCLUSIONS: Preemptive ganciclovir therapy administered daily during courses of treatment with antilymphocyte antibodies reduced the excessive occurrence of cytomegalovirus disease in renal transplant recipients who were positive for cytomegalovirus antibody. This approach, which links the most potent immunosuppression to intensive antimicrobial therapy, allows preventive therapy to be given to those patients at greatest risk for developing infectious complications. These patients are likely to benefit most from the preventive strategy.
Adolescent↗
Inhibition of cytotoxic T-lymphocyte-triggered apoptosis by target cell surface-coupled aprotinin.
A variety of recent investigations have implicated granzymes A and/or B in the target cell nuclear injury which accompanies cytotoxic T-lymphocyte-mediated cytolysis. Since soluble antiproteases have had limited efficacy in inhibiting CTL-mediated lysis, we developed a method to couple aprotinin, a peptide inhibitor of serine proteases, to the surface of target cells. Aprotinin modified by N-succinimidyl 3-(2-pyridyldithio)propionate retained trypsin-inhibitory activity, and target cells modified with aprotinin had demonstrable cell surface trypsin-inhibitory activity. Flow cytometry demonstrated that aprotinin was detectable on the target cell surface but underwent modulation at a rather rapid rate. When radiolabeled, aprotinin-coupled target cells were studied in 1-2 hr CTL assays, 51Cr release was little affected, but 125IUdR release was reduced up to 75% compared to controls. Corresponding apoptosis analysed by agarose gel electrophoresis and direct cytologic visualization was similarly reduced. Thus, aprotinin bound to the surface of target cells selectively protected target cells against CTL-mediated nuclear injury, and may serve as a model for the development of novel inhibitors of CTL-mediated lysis.
Animals↗
Cytomegalovirus infection in organ transplant recipients.
Cytomegalovirus (CMV) continues to be responsible for a substantial fraction of the morbidity and mortality that follows organ transplantation. The three major consequences of CMV infection are CMV disease (encompassing a range of clinical illness), superinfection with opportunistic pathogens, and injury to the transplanted organ. In the last decade, considerable progress has been made in elucidating risk factors for CMV disease, in rapid detection of CMV in clinical specimens, and in the use of antiviral chemotherapy and immunoglobulin to prevent and treat CMV disease after transplantation. This article discusses the impact of these advances on patient outcome following transplantation and the challenges for the next decade.
Antiviral Agents↗
Use and misuse of statistics for epidemiological studies of multiple sclerosis.
Despite a vast literature on the epidemiology of multiple sclerosis, the cause of this disease remains elusive. The majority of the studies have focused on prevalence, so that a worldwide distribution of multiple sclerosis can now be mapped. Tantalizing apparent differences in prevalence have resulted in an abundance of hypotheses about risk factors for multiple sclerosis, none of which have been firmly established. This article reviews the difficulties inherent in the use of any type of descriptive study to investigate etiology of disease and provides an update of appropriate statistical methodology to analyze study results. The major focus is on the use of analytical study design, specifically the case-control study, to investigate a specific hypothesis about association between a risk factor and multiple sclerosis. An update on new epidemiological and statistical methodology to enhance the design of future case-control studies is presented. Future opportunities to study multiple sclerosis in new ways, such as in cohort studies or nested case-control studies, using large medical insurance and other types of health-related data bases, are discussed.
Case-Control Studies↗
Clinical aspects of fungal infection in organ transplant recipients.
Fungal infections following solid organ transplantation remain a major cause of morbidity and mortality. Candida species and Aspergillus fumigatus continue to account for the majority of these infections, although the attack rate is higher among recipients of organs other than kidneys because those patients receive more immunosuppressive therapy. Although amphotericin B remains the drug of choice for treatment of invasive aspergillosis, its toxicity profile limits its widespread use. Recent experience suggests that fluconazole may be a safe and effective alternative for the treatment of fungal infections caused by Candida species or Cryptococcus neoformans. Prevention of fungal infections remains one of the most important goals in the field of transplantation. New approaches--such as the use of "preemptive therapy," or prophylaxis, for patients at greatest risk of developing infection--may assist in attainment of this goal.
Antifungal Agents↗
Angiolymphoid hyperplasia with eosinophilia (histiocytoid hemangioma): evaluation of treatment options.
Angiolymphoid hyperplasia with eosinophilia is an uncommon benign vascular proliferative lesion of unknown cause. In this report, a case is presented of a patient who was confirmed to be positive for human immunodeficiency virus and in whom the lesion had shown rapid accelerated growth. The case is used to illustrate a variety of therapeutic techniques and to evaluate the effectiveness of the various alternatives in the treatment of this unusual clinical problem. Long-term follow-up after radical excision of the tumor mass is presented.
Acquired Immunodeficiency Syndrome↗
Renal transplantation and related infections.
Although patient survival 1 year after kidney transplantation is greater than 90%, infection remains a leading cause of morbidity and death. The risk of infection is related to exposures to potential pathogens in the patient's environment (epidemiological exposures) and the patient's endogenous net state of immunosuppression. Approximately 70% of severe bacterial, fungal, and viral infections occur within 3 months of transplantation. Cytomegalovirus (CMV) infection is still the most important infectious agent following renal transplantation because of its direct effects-morbidity and mortality caused by CMV syndrome and disease, and its indirect effects-contribution to the net state of immunosuppression, which independently increases the risk of opportunistic superinfection. Management of infection in the renal-transplant recipient focuses on preventative strategies. In addition to traditional prophylactic strategies, transplant recipients may benefit from preemptive therapy, ie, therapy directed at patients who are at the greatest risk of developing clinically significant disease, at a time when the risk is maximal. Use of preemptive ganciclovir therapy for the prevention of CMV disease in CMV seropositive renal-transplant recipients during therapy with antilymphocyte antibody is an example of such a strategy. The therapeutic prescription for the transplant recipient is an effective immunosuppressive regimen combined with an anti-infective strategy to ensure its safety.
Humans↗