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Biomedical subjects

R H Rubin

Publications and source records attributed to R H Rubin.

At least 19 recordsLinked to original sources
PubMed2001

BK virus in solid organ transplant recipients: an emerging syndrome.

BK virus is a human polyomavirus associated with a range of clinical presentations from asymptomatic viruria with pyuria to ureteral ulceration with ureteral stenosis in renal transplant patients or hemorrhagic cystitis in bone marrow transplant recipients. Infection of renal allografts has been associated with diminished graft function in some individuals. Fortunately, however, the majority of patients with BK virus infections are asymptomatic. The type, duration, and intensity of immunosuppression are major contributors to susceptibility to the activation of BK virus infection. Histopathology is required for the demonstration of renal parenchymal involvement; urine cytology and viral polymerase chain reaction methods are useful adjunctive diagnostic tools. Current, treatment of immunosuppressed patients with polyomavirus viruria is largely supportive and directed toward minimizing immunosuppression. Improved diagnostic tools and antiviral therapies are needed for polyomavirus infections.

BK Virus↗
PubMed2001

Postmenopausal tubo-ovarian abscess due to Pseudomonas aeruginosa in a renal transplant patient: a case report and review of the literature.

BACKGROUND: Pseudomonas aeruginosa is an uncommon cause of infection in the female genital tract. We report a case of postmenopausal tubo-ovarian abscess (TOA) due to P. aeruginosa in a renal transplant recipient. The presentation included mild abdominal symptoms with rapid progression of peritonitis and surgical abscess drainage. This is the first such case in an organ transplant recipient described in the English literature. METHODS AND RESULTS: Published reports of 1040 cases of TOA were reviewed. The most common features were a history of sexually transmitted disease or pelvic inflammatory disease, and symptoms including abdominal pain and fever. Escherichia coli, Bacteroides spp., and Klebsiella pneumoniae were the most frequently encountered pathogens. Neisseria gonorrhoeae and Chlamydia trachomatis, which are frequently isolated from cervical cultures, are uncommonly isolated from tubo-ovarian abscesses. Forty percent of patients were treated with antibiotics alone, 18.8% with abdominal surgery, and 32% with surgery and antimicrobial therapy. CONCLUSION: This report illustrates the muted presentation and atypical microbiology of gynecologic infection in an organ transplant recipient.

Abscess↗
PubMed2001

Introduction to the Immunocompromised Host Society consensus conference on epidemiology, prevention, diagnosis, and management of infections in solid-organ transplant patients.

Infectious complications are still a significant cause of morbidity and death in solid-organ transplant patients, with significant infection being found in up to two-thirds of these individuals. The risk of infection in the organ transplant patient, particularly of opportunistic infection, is largely determined by 3 factors: the net state of immunosuppression, the epidemiologic exposures the patient encounters, and the consequences of the invasive procedures to which the patient is subjected. The most important principles of patient treatment are prevention, early diagnosis, and specific therapy. This issue is designed as a position paper by a group of experts on epidemiology, prevention, diagnosis, and management of infections in solid-organ transplant patients. We feel that our efforts may serve as an important first step in the development of guidelines in this area.

Anti-Infective Agents↗
PubMed2001

Physician-patient communication about over-the-counter medications.

The purpose of this study was to describe physician-patient communication about over-the-counter medications using a data set comprised of audio-tapes and transcripts of 414 primary care medical visits. The data set was collected during 1995 at the family practice and general medicine clinics at the University of New Mexico Health Sciences Center. Twenty-seven resident physicians and 414 of their adult patients participated. Fifty-seven percent of patients reported using one or more OTC medications during the past month. Analgesics, cold or allergy products, and antacids were the most commonly used OTC medications. White patients were significantly more likely to have reported using an analgesic in the past month than non-white patients. Female, white, and younger patients were more likely to have reported using a cold or allergy product in the past month than male, non-white, and older patients. Approximately 58% of patients discussed OTC medications with their physicians. Older patients and female patients as well as patients who reported using an antacid in the past month were significantly more likely to have discussed OTC medications with their physicians. Physicians asked questions about OTC medications during only 37% of encounters. Patients asked questions about OTC medications during 11% of encounters. Patient ethnicity did not influence physician or patient question-asking and information-giving about OTC medications. Male physicians were more likely to state information and ask questions about OTC medications than female physicians. Patients were more likely to ask male physicians questions about OTC medications. Physicians were more likely to state OTC information to and ask OTC questions of female and older patients. Physicians were more likely to ask less educated patients questions about OTC medications. Less educated patients were more likely to ask physicians questions about OTC medications. Despite the fact that more than half of all patients reported using OTC medications, physicians asked questions about OTC use during only approximately one-third of encounters. Of patients who reported using an OTC medication in the past month, 58% did not tell their physicians, yet only 14% of patients believed that it was not important for the physician to know about their OTC use. Physician-patient communication about OTC medications should be encouraged so that the patient becomes a collaborative partner in medication management.

Adolescent↗
PubMed2001

Cytomegalovirus in solid organ transplantation.

Despite substantial advances made in controlling the effects of cytomegalovirus (CMV) infection, it remains the single most important pathogen in solid organ transplantation (SOT). Because CMV shares some characteristics with other human herpesviruses, it is also an important model system for understanding the actions of herpesviruses 6 and 7, Epstein-Barr virus (EBV) and, potentially, hepatitis C and B. As the lessons learned from HIV influenced our thinking about other viral infections (e.g. importance of viral load), so too what is learned about CMV will be applied to other herpesviruses. The pervasive nature of CMV and the common problems posed by this virus prompted the convening of a panel of experts in the field of SOT to discuss issues associated with CMV in transplant recipients. This supplement reflects the presentations and discussions at this symposium, including the clinical implications of CMV drug resistance, economic impact of CMV on transplant programs, the rationale for CMV hyperimmune globulin (CMW-IGIV, CytoGam) in SOT, antibody inhibition of CMV, hypogammaglobulinemia, role of CMV in allograft vasculopathy, and the clinical use of CytoGam therapy in a variety of SOT patients. A number of questions during the general discussion prompted the addition of other material to this Supplement, including the development of CMV-IGIV for clinical use in SOT recipients and resource utilization associated with CMV-related hospital readmissions.

Antiviral Agents↗
PubMed2001

Ethnicity and physician-older patient communication about alternative therapies.

OBJECTIVES: The purpose of this study was to describe ethnic differences in physician-patient communication about alternative therapies, using a data set comprised of audiotapes and transcripts of primary care medical visits. METHODS: The data set was collected during 1995 at the family practice and general medicine clinics at the University of New Mexico Health Sciences Center, Albuquerque, NM. Twenty-seven (27) resident physicians and 205 of their Hispanic and non-Hispanic white patients age 50 and over participated. RESULTS: Almost 18 percent of patients reported using one or more alternative therapies during the preceding month. Herbal medicine was the most widely used therapy. Eighty-three percent (83%) of patients who reported using an alternative therapy in the previous month did not tell their physicians. Physicians asked one or more questions about alternative therapies during only 3.4% of encounters. Only 2% of patients asked their physicians one or more questions about alternative therapies. There were no ethnic differences in physician-older patient communication about alternative therapies. DISCUSSION: Physician-patient communication could be improved to enhance physician understanding of the spectrum of interventions patients pursue to improve their health.

Adult↗
PubMed2001

Physician gender and hormone replacement therapy discussion.

Hormone replacement therapy (HRT) is a major issue confronting millions of women today, and general internal medicine and family practice physicians are an important source of information and counseling on this issue. Previous studies have suggested that HRT discussion and prescribing are more frequent with female than with male physicians, but others have suggested age and practice setting may be the reason for observed differences. We attempted to determine if physician gender influenced HRT discussion frequency between physicians and their patients using cross-sectional, secondary analysis of data collected at general internal medicine and family practice clinics at the University of New Mexico Health Sciences Center. Twenty-seven family practice and internal medicine resident physicians (15 female, 12 male) participated. There were 127 female patients age 45 and older. Audio-taped observations of patient-physician visits collected during 1995 for a study on patient-physician communication and patient satisfaction were used. There was less frequent discussion with female than male physicians (OR = 0.42, p = 0.0014). HRT was discussed during 51 visits. Patients initiated HRT discussion in 39.2% of visits in which it was discussed. Patients with diabetes were less likely to discuss HRT (OR = 0.25, p = 0.0122). Increasing year of physician residency was associated with decreased discussion of HRT (OR = 0.51, p < 0.0001). In this health sciences center, with physicians similar in age and training, male physicians discussed HRT significantly more often than did female physicians.

Age Factors↗
PubMed2001

Resident physician management of Hispanic and non-Hispanic white patients on antidepressants.

OBJECTIVE: The purpose of this study was to examine how well resident physicians monitored Hispanic and non-Hispanic white patients who were prescribed antidepressant medication. METHOD: Retrospective and prospective review of patients' medical records. SETTING: Family practice and internal medicine clinics at the University of New Mexico Health Sciences Center. PARTICIPANTS: Twenty-six resident physicians and 109 of their Hispanic and non-Hispanic white patients who were prescribed antidepressant medication when recruited into the study between March and December 1995. MAIN OUTCOME MEASURES: (i) Whether a physician recorded an appropriate diagnosis in the patient's chart, scheduled a follow-up visit and saw the patient for a follow-up visit within four weeks of the antidepressant being prescribed, and (ii) whether a physician recorded an adequate treatment plan, a discussion of side-effects and a discussion of how well the medication was working on the date the patient was enrolled in the study. RESULTS: Twenty-seven percent of patients were prescribed antidepressant medication. Less than half of the patients who were prescribed an antidepressant had a follow-up visit scheduled and only about one-third of patients were seen by their physician within one month of the antidepressant being prescribed. Physicians documented an adequate treatment plan in the charts of 51.1% of patients, a discussion of side-effects in 11.1% of charts and an assessment of how well the medication was working in 33.3% of charts. Younger patients and patients in better emotional health were more likely to have an adequate treatment plan documented in their chart. Patients in poorer physical health were more likely to have an adequate treatment plan documented in their chart along with a description of the effectiveness of the medication. Hispanic and non-Hispanic white patients who were prescribed antidepressants were monitored equally well by their primary care physicians. CONCLUSION: Primary care resident physicians need further training on the importance of monitoring patients on antidepressant medication.

Adult↗
PubMed2001

Gastrointestinal infectious disease complications following transplantation and their differentiation from immunosuppressant-induced gastrointestinal toxicities.

It is often very difficult to distinguish between infection-related and immunosuppression-related gastrointestinal (GI) complications after transplantation. The risk of infection itself is determined by the patient's net state of immunosuppression as well as the presence of anatomic or technical abnormalities and the patient's epidemiological exposures. Of the anatomic abnormalities, diverticulitis is a particular problem in transplant patients, with a high rate of perforation and abscess formation. The causes of infectious disease syndromes are very different immediately after, early after, and late after transplantation. Infection during the first month may result from a pre-existing infection in the donor or recipient, or from the surgical wound, endotracheal tube, vascular access or drainage. During 1-6 months after transplantation, viruses attack and, with sustained immunosuppression, make opportunistic infections possible. Beyond 6 months after transplantation, the 80% of patients with good result from the transplant are at risk primarily for community-acquired microbes, including such enteric pathogens as Salmonella. Of the remaining patients, 10% have chronic viral infections and the 10% who have poor allograft function are at greatest risk for opportunistic infection. This time line is helpful in determining whether a GI complication is likely to be related to infection rather than a specific effect of an immunosuppressant drug. Fever, inflammatory cells in the stool, abnormalities on endoscopy or computed tomography and leukocytosis can be useful in the diagnosis but are inconsistent markers for an infectious cause.

Diagnosis, Differential↗
PubMed2001

Preventing opportunistic infections after hematopoietic stem cell transplantation: the Centers for Disease Control and Prevention, Infectious Diseases Society of America, and American Society for Blood and Marrow Transplantation Practice Guidelines and beyond.

This review presents evidence-based guidelines for the prevention of infection after blood and marrow transplantation. Recommendations apply to all myeloablative transplants regardless of recipient (adult or child), type (allogeneic or autologous) or source (peripheral blood, marrow or cord blood) of transplant. In Section I, Dr. Dykewicz describes the methods used to rate the strength and quality of published evidence supporting these recommendations and details the two dozen scholarly societies and federal agencies involved in the genesis and review of the guidelines. In Section II, Dr. Longworth presents recommendations for hospital infection control. Hand hygiene, room ventilation, health care worker and visitor policies are detailed along with guidelines for control of specific nosocomial and community-acquired pathogens. In Section III, Dr. Boeckh details effective practices to prevent viral diseases. Leukocyte-depleted blood is recommended for cytomegalovirus (CMV) seronegative allografts, while ganciclovir given as prophylaxis or preemptive therapy based on pp65 antigenemia or DNA assays is advised for individuals at risk for CMV. Guidelines for preventing varicella-zoster virus (VZV), herpes simplex virus (HSV) and community respiratory virus infections are also presented. In Section IV, Drs. Baden and Rubin review means to prevent invasive fungal infections. Hospital design and policy can reduce exposure to air contaminated with fungal spores and fluconazole prophylaxis at 400 mg/day reduces invasive yeast infection. In Section V, Dr. Sepkowitz details effective clinical practices to reduce or prevent bacterial or protozoal disease after transplantation. In Section VI, Dr. Sullivan reviews vaccine-preventable infections and guidelines for active and passive immunizations for stem cell transplant recipients, family members and health care workers.

Humans↗
PubMed2001

Antidepressant prescribing to Hispanic and non-Hispanic white patients in primary care.

OBJECTIVE: To examine whether there was a difference in the prescribing of selective serotonin-reuptake inhibitors (SSRIs) and non-SSRI antidepressants to Hispanic and non-Hispanic white patients in primary care. METHODS: Twenty-seven family practice and internal medicine resident physicians and 407 of their Hispanic and non-Hispanic white patients who were fluent in English or Spanish participated in the study The medical records of all patients were reviewed and information about patient diagnoses and antidepressant prescriptions was abstracted. Logistic regression was used to examine whether Hispanic ethnicity influenced physician prescribing of SSRI and non-SSRI antidepressants while controlling for other patient characteristics and diagnoses. For patients with a diagnosis of depression, logistic regression was used to examine whether Hispanic ethnicity influenced whether patients received antidepressant treatment while controlling for other patient characteristics RESULTS: Twenty-seven percent of patients received a prescription for one or more antidepressants. Hispanic and non-Hispanic white patients were equally likely to be prescribed SSRI and non-SSRI antidepressant medications. Having a diagnosis of depression and having a diagnosis of chronic pain was significantly correlated with the prescribing of a non-SSRI antidepressant (p < 0.001, p < 0.01, respectively). Having a diagnosis of depression was significantly correlated with the prescribing of an SSRI antidepressant (p < 0.001). Hispanic and non-Hispanic white patients with a diagnosis of depression were equally likely to be prescribed antidepressant treatment. Patients with a diagnosis of depression in the general medicine clinic were significantly less likely to receive antidepressant therapy than patients in the family practice clinic. CONCLUSIONS: Hispanic ethnicity did not influence antidepressant prescribing. Future research in other settings is needed to further determine whether Hispanic ethnicity influences antidepressant prescribing.

Adolescent↗
PubMed2000

Dosing of intravenous ganciclovir for the prophylaxis and treatment of cytomegalovirus infection in solid organ transplant recipients.

BACKGROUND: The optimal regimen for the prevention and treatment of cytomegalovirus (CMV) disease in solid organ transplant recipients remains to be defined, particularly for patients with abnormal or changing renal function. METHODS: A prospective trial was conducted in patients receiving i.v. ganciclovir using a standardized dosing nomogram that corrects for renal function. Steady state peak (P) and trough (T) serum levels were determined by high-performance liquid chromatography and correlated with therapeutic outcomes and toxicities attributable to ganciclovir. RESULTS: Over the study period, 44 individuals received ganciclovir prophylaxis (5 mg(kg/day) and 25 patients were treated (5 mg/kd q12 hr) for symptomatic CMV disease. Ganciclovir levels (microg/ml+/-SD) achieved in prophylaxis were P: 7.98+/-3.34, T: 3.03+/-2.63; and in treatment were P: 9.00+/-3.72, T: 2.65+/-1.82. Despite corrections for renal dysfunction, undialyzed patients with serum creatinine >3.0 mg/dl had trough levels in excess of the population mean (T: range 3-8 microg/ml). Failure of prophylaxis (disease) or therapy (relapse) occurred in 14 patients; 8 of these were at risk for primary infection (donor CMV seropositive, recipient seronegative, P<0.01). Patients at greatest risk for relapse after treatment of CMV disease were liver transplant recipients, patients with ganciclovir-resistant viral isolates, and renal patients with six antigen MHC donor-recipient mismatches. CONCLUSIONS: This trial demonstrates the efficacy of a nomogram for ganciclovir dosing during renal dysfunction; reduced doses can be used for prophylaxis for undialyzed patients with renal dysfunction (1.25 mg/kg/day for Cr > or =3.0, 1.25 mg/kg QOD for Cr > or =5.0). Some groups of transplant recipients may require more intensive anti-CMV regimens.

Adult↗