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Biomedical subjects

D Cotton

Publications and source records attributed to D Cotton.

At least 19 recordsLinked to original sources
PubMed1996

Patterns of opportunistic infections in patients with HIV infection.

The pattern of the development of opportunistic infections (OIs) in HIV-infected patients was evaluated, based on a cohort of 1,530 patients enrolled in two AIDS Clinical Trials Group anti-retroviral studies. We quantified the increase in risk of OIs associated with the occurrence of a previous OI. This assessment was based on the observed event rates of the more common AIDS-defining OIs: Pneumocystis carinii pneumonia (PCP), Mycobacterium avium complex (MAC), cytomegalovirus (CMV), and a systemic mycosis. Additionally, for each OI, we assessed the relative risks associated with a history of prior OIs, changes in CD4 levels, and baseline prognostic factors. We found that the occurrence of each of these OIs increased the risk of subsequent OIs, even after adjusting for the CD4 count. Specifically, the occurrence of PCP significantly increased the risk of MAC and CMV, and somewhat increased the risk of systemic mycoses. Diagnosis with MAC was associated with an increased risk of subsequent CMV, whereas the occurrence of CMV increased the risk of MAC. Finally, once patients were diagnosed with a systemic mycosis, they were at a somewhat increased risk of subsequently developing MAC or CMV. Although current practice for determining the timing and initiation of prophylactic therapies relies chiefly on CD4 count, the occurrence of specific AIDS-defining OIs in patients with HIV infection should also be taken into account in making decisions regarding prophylaxis strategies.

AIDS-Related Opportunistic Infections↗
PubMed1996

Third-trimester arterial blood gas and acid base values in normal pregnancy at moderate altitude.

OBJECTIVE: To report arterial blood gas and acid base values of normal nulliparous patients at moderate altitude for commonly used maternal positions. METHODS: Ten normotensive nulliparous women between 36 and 38 weeks' gestation volunteered to undergo radial and pulmonary artery cannulation as part of a larger study. Following instrumentation, baseline assessments were made in the left lateral recumbent position after a 30-minute stabilization period. Sequential measurements were then obtained in the left lateral, right lateral, supine, knee-chest, sitting, and standing positions. Blood samples were analyzed in duplicate for oxygen content on a blood gas analyzer. Statistical analysis was performed by analysis of variance of repeated measures with significance defined at P < or = .05. RESULTS: There was no significant difference in arterial blood gas or acid base values between any positions in this antepartum population of term healthy women. The composite mean values were as follows: pH 7.46, arterial carbon dioxide pressure (PaCO2) 26.6 mmHg, arterial oxygen pressure 88.3 mmHg, bicarbonate 18.2 mEq/L, saturated arterial hemoglobin level 0.96. CONCLUSION: Arterial blood gas and acid base values are not altered by maternal position in the late third trimester of pregnancy. The PaO2 in these women studied at moderate altitude was lower than previously reported for healthy pregnant women studied at sea level. Appropriate interpretation of arterial blood specimens of pregnant women should take into account both the pregnancy and altitude at which the women reside.

Acid-Base Equilibrium↗
PubMed1996

A model of community mobilization for the prevention of HIV in women and infants. Prevention of HIV in Women and Infants Demonstration Projects.

The prevention of HIV in Women and Infants Demonstration Projects use a conceptual model for maximizing broad community participation for HIV prevention called the Community Mobilization Framework. The projects' comprehensive approach attempts to bring about changes on a community level using a model which encourages community-wide participation of persons with various roles and relationships in the community. The Community Mobilization Framework is one way to systematically conceptualize the organization of the community for the purpose of mobilizing the maximum number of community members around a common health initiative. A community becomes mobilized around an issue by endorsing health-enhancing attitudes, behaviors, and projects supporting positive health outcomes. This mobilization is expressed through the promotion, support, and delivery of motivational and informational health messages which convey consistent ideas, themes, and images. There are two fundamental bases of the Community Mobilization Framework. The first is its characterization of the variety of individual, social, and organizational roles and relationships in the community that might be used in a concerted campaign for HIV prevention for women. The second basis of the model is the description of the nature and extent of the involvement, which includes a continuum of involvement, ranging from simple endorsement to building active coalitions around a health initiative. The paper discusses practical methods of applying these principles, with the Women and Infants Demonstration Projects providing concrete examples.

Acquired Immunodeficiency Syndrome↗
PubMed1993

The diagnostic and prognostic value of amniotic fluid white blood cell count, glucose, interleukin-6, and gram stain in patients with preterm labor and intact membranes.

OBJECTIVE: Our goal was to compare the value of amniotic fluid tests in the detection of microbial invasion of the amniotic cavity and in the relationship with the amniocentesis-to-delivery interval and neonatal complications in patients with preterm labor and intact membranes. STUDY DESIGN: Amniotic fluid was retrieved by transabdominal amniocentesis from 120 patients with preterm labor and intact membranes. Fluid was cultured for aerobic and anaerobic bacteria and for mycoplasmas. Amniotic fluid analysis included a Gram stain, white blood cell count, glucose and interleukin-6 determinations. Logistic regression and Cox's proportional hazards model were used for analysis. RESULTS: (1) The prevalence of positive amniotic fluid cultures was 9.2% (11/120); (2) patients with microbial invasion had a shorter amniocentesis-to-delivery interval and a higher neonatal complications rate than patients with a negative culture; (3) the most sensitive test for the detection of microbial invasion of the amniotic cavity was amniotic fluid interleukin-6 determinations (cutoff 11.3 ng/ml) (sensitivity; for interleukin-6 100%, for glucose 81.8%, for white blood cell count 63.6%, and for Gram stain 63.6%; p < 0.05 for all comparisons); (4) the most specific test was the Gram stain of amniotic fluid (specificity: for Gram stain 99.1%, for white blood cell count 94.5%, for interleukin-6 82.6%, and for glucose 81.6%; p < 0.01 for all); (5) of all amniotic fluid tests, interleukin-6 determinations were the only ones that had significant relationship with the amniocentesis-to-delivery interval and neonatal complications. CONCLUSION: Interleukin-6 concentrations in amniotic fluid are better indicators of microbial invasion of the amniotic cavity, amniocentesis-to-delivery interval, and neonatal complications than the amniotic fluid Gram stain, glucose concentration, or white blood cell count.

Adult↗
PubMed1993

Relationship between the fetal biophysical profile score, umbilical artery Doppler velocimetry, and fetal blood acid-base status determined by cordocentesis.

OBJECTIVE: Fetal hypoxia-acidosis is part of the terminal pathway leading to intrauterine fetal death. A central premise of antepartum surveillance is that identification and timely delivery of the hypoxic or acidotic fetus will prevent intrauterine death and decrease long-term neurologic damage. The optimal method to identify fetal hypoxia-acidosis has not been determined. We attempted to compare the performance of the biophysical profile score and umbilical artery Doppler velocimetry in the identification of fetal acidemia, hypoxemia, and hypercarbia as determined by pH and gas analysis of fetal blood obtained by cordocentesis. STUDY DESIGN: Fetal biophysical profile and umbilical artery Doppler velocimetry studies were performed before cordocentesis in 24 patients (26 to 40 weeks). Umbilical vein pH and blood gas values were determined in all cases. The pulsatility index of the umbilical artery was obtained with pulsed Doppler equipment. Receiver-operator characteristic curve analysis and stepwise multiple logistic regression were performed to examine the relationship between biophysical profile score, umbilical artery Doppler velocimetry, and acid-base status. RESULTS: The prevalence of fetal acidemia (pH 2 SD below the mean for gestational age) was 41.7% (10/24). There was a significant relationship between the change in umbilical artery pulsatility index and fetal acidemia (chi 2 = 26.6, p < 0.001) and hypercarbia (chi 2 = 22.9, p < 0.001), but not hypoxemia (chi 2 = 1.0, p > 0.1), and between the biophysical profile score and fetal acidemia (chi 2 = 11.1, p < 0.001) and hypercarbia (chi 2 = 9.0, p < 0.005), but not hypoxemia (chi 2 = 2.3, p > 0.1). Stepwise multiple logistic regression demonstrated that umbilical artery Doppler velocimetry was a better explanatory variable for acidemia and hypercarbia than the biophysical profile score. CONCLUSION: A strong relationship between the degree of fetal acidemia and hypercarbia and the results of umbilical artery Doppler velocimetry and biophysical profile was found. However, umbilical artery Doppler velocimetry was a better explanatory variable for these outcome than the biophysical profile score.

Acid-Base Equilibrium↗
PubMed1993

Candida epididymitis: newly recognized opportunistic epididymal infection.

Epididymitis is common, yet it is rarely associated with fungal pathogens. We report a case of Candida albicans epididymitis in a diabetic which was ultimately treated by orchiectomy. Opportunistic infections of the genitourinary tract in immunosuppressed patients are becoming more prevalent; examples include fungal infections in patients with acquired immune deficiency syndrome or after organ transplant. The fact that opportunistic organisms can invade the epididymis and produce infection suggests that in cases of persistent epididymitis, which have failed to respond to conventional therapy, more aggressive diagnostic procedures should be considered. Needle aspiration with cultures for fungus and viral organisms should be performed. This is especially true in patients with preexisting chronic illness or an immune compromised state.

Aged↗
PubMed1993

An electronic medical record that helps care for patients with HIV infection.

We have built a clinical workstation to help doctors and nurses care for patients with HIV infection. This knowledge-based medical record system provides medication alerts, reminders about primary care, and on-line information to support the care of patients with HIV infection. We are conducting a controlled clinical trial of this computer system in a single practice setting, which consists of 18 staff physicians, 13 nurses, and 113 residents, who cooperatively practice in four teams. Two teams of physicians are assigned to an intervention group and two teams to a control group. This paper reports preliminary results from the first year of study, January 15, 1992, through January 14, 1993. During this period 274 patients with HIV infection were followed by the general medical practice--130 in a control group and 144 in an intervention group. Physicians in the intervention group more rapidly and more completely followed primary care guidelines than did physicians in the control group. Patients in the intervention group had 2476 ambulatory or emergency visits (17.2 visits per patient) compared with 1882 visits (14.5 visits per patient) for the control patients (p < 0.01). There were 101 hospitalizations for 51 patients in the intervention group (an admission rate of 0.7) compared with 104 admissions for 54 patients in the control group (an admission rate of 0.8) (p = NS). There were 8 deaths in the intervention group (5.6%) compared with 13 (10%) in the control group (p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Artificial Intelligence↗
PubMed1992

Molecular approach in spider mites (Acari: Tetranychidae): preliminary data on ribosomal DNA sequences.

DNA sequence data were used to examine phylogenetic relationships between six species of economically important Tetranychidae mites: Eotetranychus carpini (Oudemans), E. pruni (Reck), Tetranychus pacificus McGregor, T. mcdanieli McGregor, T. turkestani Ugarov & Nikolski and T. urticae Koch. With primers directed toward conserved elements flanking the target region, the Polymerase Chain Reaction was used to amplify the ITS2 spacer of the ribosomal DNA molecule. The nucleotide sequence of a 300-bp fragment of the ITS2 was determined by direct sequencing and nucleotide divergence used for intra-generic comparison in mites. The resulting phylogenetic tree expressing interspecific relationships in genus Tetranychus agrees with morphological data. The study demonstrates the usefulness of the approach in the assessment of the systematics and evolution of the group.

Acari↗
PubMed1992

What is the dentist's occupational risk of becoming infected with hepatitis B or the human immunodeficiency virus?

Surveys have shown that dentists are reluctant to treat persons infected with the human immunodeficiency virus (HIV). However, dentists are much more willing to treat patients with infectious hepatitis B virus (HBV). This study shows that the annual cumulative risk of infection from routine treatment of patients whose seropositivity is undisclosed is 57 times greater from HBV than from HIV, and that the risk of dying from HBV infection is 1.7 times greater than the risk of HIV infection, for which mortality is almost certain.

Attitude of Health Personnel↗
PubMed1991

Amphotericin B vs high-dose ketoconazole for empirical antifungal therapy among febrile, granulocytopenic cancer patients. A prospective, randomized study.

We compared high-dose ketoconazole (800 mg/kg per day, orally) with amphotericin B (0.5 mg/kg per day, intravenously) for empirical antifungal therapy in a prospective, randomized study of persistently or recurrently febrile granulocytopenic cancer patients. Among 97 patients eligible for empirical antifungal therapy, 20 (21%) of these patients were ineligible for randomization to ketoconazole treatment because of their inability to tolerate oral medications. Among 72 patients eligible for randomization, 64 were assessable (32 in each arm of the study). Five of six patients with proved fungal infections who were randomized to receive ketoconazole treatment required crossover to amphotericin B treatment because of progressive infection. The conditions of three of these five patients improved after receiving amphotericin B. The frequency of transaminase elevation was higher in those receiving ketoconazole, while the frequency of azotemia was higher in those receiving amphotericin B. Bioavailability of ketoconazole was unpredictable. Amphotericin B remains the drug of choice for empirical antifungal therapy in granulocytopenic patients; whereas, lack of a parenteral formulation, ineffectiveness against proved mycoses, and unreliable bioavailability preclude high-dose ketoconazole from being an appropriate compound for this purpose.

Adult↗
PubMed1990

A randomized trial of open lung biopsy versus empiric antimicrobial therapy in cancer patients with diffuse pulmonary infiltrates.

Twenty-four cancer patients with diffuse interstitial pneumonitis (DIP) were randomized to undergo an open lung biopsy (OLB) within 8 hours of presentation (12 patients) or to receive empiric antimicrobial therapy (ET) with trimethoprim-sulfamethoxazole (TMP-SMX) erythromycin for a minimum of 4 days (12 patients). Patients whose condition deteriorated underwent an OLB on day 4. Eight of 12 patients (67%) having OLB survived versus 10 of 12 (83%) receiving ET (P = .64). Morbidity occurred in nine of 12 (75%) having OLB versus eight of 12 (67%) receiving ET (P = 1.0). Concurrently, there were 14 additional cancer patients with DIP who were not randomized (nine refused, three had a coagulopathy contraindicating surgery, two were excluded by primary care physicians) and who were comparable demographically to the randomized group. Two received OLB and 12 ET. Combining the randomized and nonrandomized groups, eight of 14 (57%) having an initial OLB survived versus 18 of 24 (75%) of ET-treated patients (P2 = .19). Results of the OLB were seven Pneumocystis carinii pneumonia (PCP), five nonspecific pneumonitis (NSP), one cytomegalovirus, and one lymphoma. Results of OLB led to discontinuation of antibiotics in three patients. Of the 24 ET patients, eight failed to improve by day 4 and had an OLB. Results were two NSP, two PCP, two cancer, one blastomycosis, and one Candida pneumonia. Complications were seen in 10 of 14 (72%) initial OLB patients versus 14 of 24 (58%) patients on the ET arm (P = .65). When the complication rate between patients receiving only empiric antibiotics was compared with all patients having an OLB (initially or on day 4), the difference was greater in patients undergoing OLB (37% v 72%, respectively) (P2 = .14). ET with TMP-SMX plus erythromycin and broad spectrum antibiotics in granulocytopenic patients appeared to be as successful and potentially less toxic than an OLB in this study. Although the number of patients in this study was small, these data suggest that a trial of empiric antibiotic management may be reasonable in cancer patients presenting with DIP, especially if they are nonneutropenic.

Adult↗
PubMed1986

A randomized trial comparing ceftazidime alone with combination antibiotic therapy in cancer patients with fever and neutropenia.

To assess the efficacy of single-agent therapy relative to standard combination antibiotic therapy for the initial management of fever and neutropenia in cancer patients, we conducted a randomized trial comparing ceftazidime alone with a combination of cephalothin, gentamicin, and carbenicillin. Of 550 evaluable episodes of fever and neutropenia, 282 were treated with ceftazidime alone and 268 with the combination. All episodes were evaluated for responses at 72 hours after the start of treatment and at resolution of the neutropenia. Of the patients with unexplained fever who were given ceftazidime alone, 99 percent were alive at 72 hours and 98 percent were alive when the neutropenia resolved, as compared with 100 percent and 98 percent, respectively, of those given combination therapy. Of the patients with documented infection who were given ceftazidime alone, 98 percent were alive at 72 hours and 89 percent when the neutropenia resolved, as compared with 98 percent and 91 percent, respectively, of those given combination therapy. The majority of episodes of documented infection in both treatment groups necessitated additional antimicrobial treatment or other modifications of the initial regimen, as compared with only 22 percent of the episodes of unexplained fever. We conclude that initial single-agent therapy with certain beta-lactam antibiotics is a safe alternative to standard combination antibiotic therapy, although patients with documented infection or protracted neutropenia are likely to require additional or modified treatment.

Adolescent↗
PubMed1985

New beta-lactam antibiotics in granulocytopenic patients. New options and new questions.

Infectious complications are a frequent cause of morbidity and, at many centers, the major cause of death in patients with cancer. The increased risk and severity of infectious sequelae result from profound alterations in normal host defenses that occur secondary to the underlying malignancy and the treatment thereof. During the last decade, early empiric antibiotic therapy has become standard practice in the initial management of febrile granulocytopenic patients and has contributed significantly to the improved outcome among patients undergoing cancer therapy. Although early death due to unsuspected or inadequately treated bacterial infection has been largely overcome, new problems--also with life-threatening implications--have emerged. As the use of cancer chemotherapy continues to increase, new populations of patients are being placed at increased risk of infection. Defining the host and environmental factors that contribute to this risk assumes central importance for delineating those patients who require the most intense surveillance. Changing medical practices (e.g., increased use of indwelling catheters) have contributed to the emergence of new pathogens. Recent drug developments (e.g., the third-generation cephalosporins and extended-spectrum penicillins) offer new treatment options, as well as generate controversy and confusion. For example, authorities disagree on the optimal duration and modifications in treatment that are required by cancer patients who remain granulocytopenic and who thus are at continued risk of multiple infectious episodes or superinfections. A question of current interest is whether combination therapy with synergistic agents is important in light of the development of the third-generation cephalosporins and extended-spectrum penicillins. Several of these new antibiotics have an exceedingly broad spectrum of activity that includes Pseudomonas aeruginosa, as well as Enterobacteriaceae, Serratia, Citrobacter, indole-positive Proteus, and anaerobes (including Bacteroides fragilis). However, the third-generation cephalosporins are not as active against staphylococci and streptococci as are the first-generation cephalosporins, and none is effective against enterococci. Nonetheless, these agents achieve serum levels that can be 10 to 100 times greater than the minimal inhibitory and bactericidal concentrations of gram-negative bacteria, raising the possibility that these drugs might be effective as single agents. The advantages of the third-generation cephalosporins are their minimal toxicity and long serum half-lives.(ABSTRACT TRUNCATED AT 400 WORDS)

Agranulocytosis↗
PubMed1985

Peripartum colloid osmotic pressure changes: effects of controlled fluid management.

A prospective, fluid-controlled study of serially measured colloid osmotic pressure changes in the peripartum period was undertaken. Seventeen patients with uncomplicated pregnancies undergoing elective cesarean section at term were administered a predelivery bolus of 15 ml/kg of lactated Ringer's solution prior to operation. Maintenance crystalloid fluids were infused at 125 to 150 ml/hr both intraoperatively and post partum without the addition of blood or other colloid solutions. Serial colloid osmotic pressure measurements were obtained before hydration, after hydration, after delivery, and at 6 and 24 hours post partum. The results demonstrated a 15.9% decline in colloid osmotic pressure immediately following the hydration bolus (20.7 +/- 1.5 to 17.4 +/- 1.8 mm Hg) (p less than 0.01). A further decline in colloid osmotic pressure to 16.6 +/- 1.7 mm Hg occurred after delivery and represented an overall 22% decrease from the baseline value (p less than 0.05). The lowest mean colloid osmotic pressure value occurred at 6 hours post partum (16.1 +/- 1.1 mm Hg). These data support previous observations that colloid osmotic pressure is uniformly lowered in the immediate postpartum period with peak reductions identified at 6 hours following delivery. In addition, intravenous crystalloid administration during the peripartum interval can substantially influence this decline in colloid osmotic pressure. Although no clinical evidence of cardiopulmonary compromise was observed in this set of normal gravid women, these data may be useful in the management of the parturient patient with established risk factors for pulmonary edema where alterations in the pulmonary capillary wedge pressure-colloid osmotic pressure gradient have been shown to correlate with the development of this complication.

Cesarean Section↗
PubMed1985

Prospective randomized study of open lung biopsy versus empirical antibiotic therapy for acute pneumonitis in nonneutropenic cancer patients.

Diffuse pulmonary infiltrates and acute respiratory compromise frequently occur in patients with cancer who are undergoing chemotherapy, and treatment remains controversial. We initiated a prospective randomized trial in 22 nonneutropenic patients to compare the efficacy of immediate open lung biopsy with that of empirical trimethoprim-sulfamethoxazole and erythromycin therapy with delayed open lung biopsy if no clinical improvement occurred after 4 days of therapy. Diagnoses included non-Hodgkin's lymphoma (15 patients), T-cell lymphoma (2), acute lymphoblastic leukemia (3), Hodgkin's disease (1), and breast cancer (1). The median age was 40 years, and fever (18) and tachypnea (13) were the most frequent signs. Median room air arterial oxygen tension in 18 hypoxic patients was 53 mm Hg; 19 patients had diffuse pulmonary infiltrates. Eight of the 10 patients randomized to empirical antibiotic therapy showed improvement after 4 days. The 2 patients whose condition did not improve and who underwent delayed open lung biopsy had Pneumocystis carinii pneumonia. One of them did show improvement, and the other died of respiratory failure. Time to clinical resolution in the 9 surviving patients was 14 days; 4 required prolonged ventilation (longer than 24 hours). Findings for the 12 patients randomized to immediate open lung biopsy were P. carinii pneumonia in 7 and nonspecific pneumonitis in 5; there were 3 deaths related to open lung biopsy. Time to resolution in the surviving patients was 13 days for those with P. carinii pneumonia and 5 days for those with nonspecific pneumonitis; 7 required prolonged ventilation.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗