Biomedical subjects

Peter Bacchetti

Publications and source records attributed to Peter Bacchetti.

At least 37 records · Page 2Linked to original sources

PubMed2004

Association between syphilis, antibodies to herpes simplex virus type 2, and recreational drug use and hepatitis B virus infection in the Women's Interagency HIV Study.

BACKGROUND: Liver disease is a leading cause of death in human immunodeficiency virus (HIV)-infected women; however, risk factors for hepatitis b virus (hbv) infection in this population have not been well studied. METHODS: We describe the seroprevalence and predictors of HBV infection in a cross-sectional analysis of 2132 women with and at risk for HIV infection enrolled in the Women's Interagency HIV Study during the periods 1994-95 and 2001-02. Any test result positive for antibody to hepatitis B core antigen defined infection; those women with serological evidence of vaccine immunity were excluded from analysis. Women were stratified into those with a history of injection drug use (IDU), those with a history of noninjection drug use (non-IDU), and those with no history of illicit drug use. RESULTS: Of 1606 HIV-infected and 526 HIV-uninfected women, 7% and 12%, respectively, appeared to be vaccine immune. After exclusion of these women, 43% of 1500 HIV-infected and 22% of 461 HIV-uninfected women had HBV infection. HBV infection prevalence differed among the IDU, non-IDU, and no illicit drug use groups (76%, 30%, and 17%, respectively; P<.0001). HBV infection was strongly associated with herpes simplex virus 2 (HSV-2) seropositivity in the IDU group (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.6-5.4) and with a history of syphilis in the non-IDU group (OR, 2.7; 95% CI, 1.4-5.0). DISCUSSION: We found a high prevalence of HBV infection in our cohort of women with and at risk for HIV infection. HSV-2 seropositivity and a history of syphilis appeared to be important correlates of HBV infection. Sexual transmission of HBV, particularly in those with a history of genital ulcer disease, should be a major focus of education in all high-risk groups.

Adult↗

PubMed2004

HIV-producing T cells in cerebrospinal fluid.

In HIV-1-infected subjects, the magnitude of HIV-1 viral load in cerebrospinal fluid (CSF) correlates with the CSF white cell count. To determine whether HIV-1-producing T cells appear in CSF and whether their percentage and number correlate with viral load in CSF, we developed a flow cytometric assay that detects HIV-1-producing T cells by identifying intracellular p24 HIV-1 antigen. We found that most CSF T cells were not HIV-1 producing, even when cell-free viral load in CSF was high. Most activated T cells in CSF were also not HIV-1 producing, but the activated CD38+ CD4 T-cell fraction in CSF was independently associated with the fraction of HIV-1-producing T cells in CSF. We conclude that HIV-1-producing T cells appear in CSF and that their percentage and number correlate with cell-free viral load in CSF, even though the CSF total white cell count remains the best predictor for CSF viral load. In HIV-1 infection, CSF white cell counts seem to contain a large number of uninfected cells. White cell counts and viral load in CSF may result from systemic inflammation and immune activation.

Adult↗

PubMed2004

High rates of sustained smoking cessation in women hospitalized with cardiovascular disease: the Women's Initiative for Nonsmoking (WINS).

BACKGROUND: Although men hospitalized with cardiovascular disease (CVD) show high smoking-cessation rates, similar data for women are lacking. We tested the efficacy of smoking-cessation intervention in women hospitalized for CVD. METHODS AND RESULTS: In this randomized controlled trial conducted from 1996 to 2001, 277 women diagnosed with CVD (mean age 61+/-10 years) were randomly assigned within 1 of 12 San Francisco Bay Area hospitals to a usual-care group (UG; n=135) or intervention group (IG; n=142). Baseline histories were obtained, and interviews to ascertain self-reported smoking status occurred at 6, 12, 24, and 30 months after hospitalization. The UG received strong physician's advice, a self-help pamphlet, and a list of community resources. The IG received strong physician's advice and a nurse-managed cognitive behavioral relapse-prevention intervention at bedside, with telephone contact at intervals after discharge. The groups were similar demographically and had smoked cigarettes for a median of 38 (IG) or 40 (UG) years. Time to resumption of continuous smoking was assessed by Kaplan-Meier analysis, and risk differences between groups were determined. Time smoke-free was significantly greater for the IG than the UG (P=0.038). Point prevalence for nonsmoking at the interviews was somewhat greater for the IG than the UG (P>0.15 at all times). CONCLUSIONS: Cognitive behavioral intervention resulted in longer average times to resumption of smoking, but in these 2 groups of older women with limited social and financial resources, long-term success rates were similar. Systematic identification of smokers and even the brief intervention afforded the UG yielded a high smoking-cessation rate over time.

Adult↗

PubMed2004

Prediction of survival after liver retransplantation for late graft failure based on preoperative prognostic scores.

The current policy for determining priority for organ allocation is based on the model for end stage liver disease (MELD). We hypothesize that severity of graft dysfunction assessed by either the MELD score or the Child-Turcotte-Pugh (CTP) score correlates with mortality after liver retransplantation (re-OLT). To test this hypothesis, we analyzed the outcome of 40 consecutive patients who received re-OLT more than 90 days after primary orthotopic liver transplantation (OLT). The Kaplan-Meier 1-year and 5-year survival rates after re-OLT were 69% and 62%, respectively. The area under the curve (AUC) values generated by the receiver operating characteristics (ROC) curves were 0.82 (CI 0.70-0.94) and 0.68 (CI 0.49-0.86), respectively (P =.11), for the CTP and MELD models in predicting 1-year mortality after re-OLT. The 1-year and 5-year survival rates for patients with CTP scores less than 10 were 100% versus 50% and 40%, respectively, for CTP scores of at least 10 (P =.0006). Patients with MELD scores less than or equal to 25 had 1-year and 5-year survival rates of 89% and 79%, respectively, versus 53% and 47%, respectively, for MELD scores greater than 25 (P =.038). Other mortality predictors include hepatic encephalopathy, intensive care unit (ICU) stay, recurrent hepatitis C virus (HCV) infection, and creatinine level of 2 mg/dL or higher. Analysis of an independent cohort of 49 patients showed a trend for a correlation between CTP and MELD scores with 1-year mortality, with AUC of 0.59 and 0.57, in respective ROC curves. In conclusion, our results suggest that severity of graft failure based on CTP and MELD scores may be associated with worse outcome after re-OLT and provide a cautionary note for the "sickest first" policy of organ allocation.

Adult↗

PubMed2004

Variation in care for nonmelanoma skin cancer in a private practice and a veterans affairs clinic.

BACKGROUND: Nonmelanoma skin cancer is the most common malignancy. Multiple therapies prevent recurrence but vary widely in cost. The most common therapies are local destruction, excision, and Mohs surgery (histologically guided tumor removal). Clinical variables that may affect treatment choices can be identified, but little is known about how clinicians choose among therapies. OBJECTIVE: The objective of this study was to learn if variations exist in the treatment of nonmelanoma skin cancer in different practice settings. RESEARCH DESIGN: Prospective cohort study. SUBJECTS: Subjects consisted of consecutive patients with nonmelanoma skin cancer at a university-affiliated private dermatology practice and the dermatology clinic at the nearby affiliated Veterans Affairs (VA) medical center. DATA: We studied data from medical records and patient surveys. RESULTS: Overall, 1777 nonrecurrent nonmelanoma skin cancers were diagnosed in 1375 patients. Compared with the VA site, patients at the private site were younger, more likely to be female, and less likely to be poor, and their tumors were smaller and less likely to be on visible areas of the body. Treatments varied between the 2 sites (P <0.001). The proportions of tumors treated at the private and VA sites, respectively, were 23% and 19% for destruction, 25% and 48% for excision, and 37% and 25% for Mohs surgery. In multiple clinical subgroups, Mohs surgery was more likely to be performed at the private site than at the VA. Moreover, in multivariable models controlling for clinical features that may have affected treatment choice, tumors at the private site were more likely than tumors at the VA to be treated with Mohs surgery (odds ratio, 2.39; 95% confidence interval, 1.54-3.70). CONCLUSIONS: Care for nonmelanoma skin cancer varied at 2 academic practice sites that are near each other and that share some clinician staff. These findings raise questions not only about overuse or underuse of procedures at the 2 sites, but also about systematic differences in patient preferences and/or physician incentives in prepaid and fee-for-service settings.

Age Factors↗

PubMed2004

Human immunodeficiency virus type 1 superinfection was not detected following 215 years of injection drug user exposure.

Evidence for human immunodeficiency virus type 1 (HIV-1) superinfection was sought among 37 HIV-1-positive street-recruited active injection drug users (IDUs) from the San Francisco Bay area. HIV-1 sequences from pairs of samples collected 1 to 12 years apart, spanning a total of 215 years of exposure, were generated at p17 gag, the V3-V5 region of env, and/or the first exon of tat and phylogenetically analyzed. No evidence of HIV-1 superinfection was detected in which a highly divergent HIV-1 variant emerged at a frequency >20% of the serum viral quasispecies. Based on the reported risk behavior of the IDUs and the HIV-1 incidence in uninfected subjects in the same cohort, a total of 3.4 new infections would have been expected if existing infection conferred no protection from superinfection. Adjusted for risk behaviors, the estimated relative risk of superinfection compared with initial infection was therefore 0.0 (95% confidence interval, 0.00, 0.79; P = 0.02), indicating that existing infection conferred a statistically significant level of protection against superinfection with an HIV-1 strain of the same subtype, which was between 21 and 100%.

Adult↗

PubMed2003

Short-term effects of cannabinoids in patients with HIV-1 infection: a randomized, placebo-controlled clinical trial.

BACKGROUND: Cannabinoid use could potentially alter HIV RNA levels by two mechanisms: immune modulation or cannabinoid-protease inhibitor interactions (because both share cytochrome P-450 metabolic pathways). OBJECTIVE: To determine the short-term effects of smoked marijuana on the viral load in HIV-infected patients. DESIGN: Randomized, placebo-controlled, 21-day intervention trial. SETTING: The inpatient General Clinical Research Center at the San Francisco General Hospital, San Francisco, California. PARTICIPANTS: 67 patients with HIV-1 infection. INTERVENTION: Participants were randomly assigned to a 3.95%-tetrahydrocannabinol marijuana cigarette, a 2.5-mg dronabinol (delta-9-tetrahydrocannabinol) capsule, or a placebo capsule three times daily before meals. MEASUREMENTS: HIV RNA levels, CD4+ and CD8+ cell subsets, and pharmacokinetic analyses of the protease inhibitors. RESULTS: 62 study participants were eligible for the primary end point (marijuana group, 20 patients; dronabinol group, 22 patients; and placebo group, 20 patients). Baseline HIV RNA level was less than 50 copies/mL for 36 participants (58%), and the median CD4+ cell count was 340 x 109 cells/L. When adjusted for baseline variables, the estimated average effect versus placebo on change in log10 viral load from baseline to day 21 was -0.07 (95% CI, -0.30 to 0.13) for marijuana and -0.04 (CI, -0.20 to 0.14) for dronabinol. The adjusted average changes in viral load in marijuana and dronabinol relative to placebo were -15% (CI, -50% to 34%) and -8% (CI, -37% to 37%), respectively. Neither CD4+ nor CD8+ cell counts appeared to be adversely affected by the cannabinoids. CONCLUSIONS: Smoked and oral cannabinoids did not seem to be unsafe in people with HIV infection with respect to HIV RNA levels, CD4+ and CD8+ cell counts, or protease inhibitor levels over a 21-day treatment.

Administration, Oral↗

PubMed2003

Trends in human immunodeficiency virus seroincidence among street-recruited injection drug users in San Francisco, 1987-1998.

This paper reports trends in human immunodeficiency virus (HIV) incidence among street-recruited injection drug users (IDUs) in San Francisco, California, from 1987 through 1998, estimated using a sensitive/less sensitive enzyme immunoassay testing strategy. IDUs were enrolled in 23 semiannual cross-sections from three community sites. For identification of recent infections, less sensitive enzyme immunoassay testing was performed on stored specimens that had previously tested positive for HIV antibodies. Annualized incidence rates were calculated and logistic regression models were fitted for assessment of risk factors for recent HIV infection. Among 8,065 susceptible IDUs, 34 had recent infections, for an incidence rate of 1.2% (95% confidence interval: 0.7, 2.0) per person-year. This rate declined from 2.7% in 1987/1988 to approximately 1% per person-year between 1989 and 1998. Two IDU subpopulations were at highest risk for infection: persons under age 30 years (2.8% per person-year) and men who had sex with men (3.0% per person-year). Participants who reported prior HIV test-result counseling were less likely than others to become infected (adjusted odds ratio = 0.43, 95% confidence interval: 0.21, 0.87). Sensitive/less sensitive enzyme immunoassay testing is an effective tool for assessing HIV incidence. HIV incidence among street-recruited IDUs in San Francisco appears to have remained stable and moderate since the late 1980s.

Adult↗

PubMed2003

Serum albumin is a powerful predictor of survival among HIV-1-infected women.

BACKGROUND: We previously reported that single measurements of albumin strongly predict survival in HIV-1-infected women independent of disease-specific markers. We now extend this to the use of serial measurements and single albumin values prior to initiation of highly active antiretroviral therapy. DESIGN: Prospective cohort study of 1941 women enrolled at six sites in the Women's Interagency HIV Study. RESULTS: Albumin fell 0.44 g/L/y in 1627 women who survived and at a faster rate in 397 who died (1.54 g/L/y; p <.01). In a time-dependent model adjusting for disease markers, the relative hazard (RH) was fivefold higher in patients with serum albumin <35 g/L compared with patients with serum albumin >42 g/L. The RH of serum albumin <35 g/L in women with CD4+ lymphocyte counts > or =200 cells/micro L was 8.2 [95% CI: 4.2-15.8]) versus only 3.8 [95% CI: 2.4-6.1] in those with counts <200 cells/mm3. In a fixed-covariate Cox analysis of patients who started HAART during the study, albumin prior to HAART was associated with a higher RH (7.0 for albumin <35 g/L versus >42 g/L) than were other factors. CONCLUSION: Serum albumin is a strong independent predictor of mortality in HIV-1-infected women after adjustment for known disease markers and may be useful for clinical monitoring.

Adult↗

PubMed2003

Sirolimus prolongs recovery from delayed graft function after cadaveric renal transplantation.

Sirolimus, lacking known nephrotoxicity, appeared to be an ideal immunosuppressive agent in the setting of delayed graft function (DGF) after renal transplantation. Coincident with our use of sirolimus however, we noticed prolongation of DGF. To investigate possible causes of prolonged DGF, extensive donor, recipient, transplant, and post-transplant data were collected on 132 consecutive cases of DGF at the University of California, San Francisco between 1/1/97 and 6/30/01. Cox proportional hazards analysis of time to graft function was used in univariate and multivariate models to identify factors that prolong DGF. Sirolimus had a large and highly significant effect on time to graft function (hazard ratio 0.48, p = 0.0007). The hazard ratio indicates that a recipient on sirolimus is half as likely to resolve DGF or twice as likely to remain on dialysis as a recipient without sirolimus. Two other factors had less potent but still significant association with DGF duration: recipient sensitization (hazard ratio 0.66, p = 0.037), and Novartis score (hazard ratio 0.93 per 1.0 increase; p = 0.034). Sirolimus retained its profound negative association with time to graft function in all multivariate models. Because sirolimus appears to prolong DGF, it may not be the optimal immunosuppressive choice in the DGF setting.

Adult↗

PubMed2003

Factors associated with future amputation among patients undergoing hemodialysis: results from the Dialysis Morbidity and Mortality Study Waves 3 and 4.

BACKGROUND: Amputation is more common in hemodialysis patients than in the general population, but risk factors for amputation in this population have not been studied extensively. METHODS: We used the US Renal Data System Dialysis Morbidity and Mortality Study Waves 3 and 4 in combination with Medicare discharge data to identify factors associated with lower-extremity amputation (excluding toe amputations) in hemodialysis patients. We used stepwise multivariable logistic regression analysis to identify variables most strongly associated with amputation within 2 years of the study start date. RESULTS: Male sex, diabetes, previous diagnosis of peripheral vascular disease (PVD), mean systolic blood pressure, and elevated serum phosphorus level were associated with the outcome of amputation within 2 years of the study start date. Among patients without diabetes, a previous diagnosis of cardiac disease, longer time from initiation of dialysis therapy (vintage), and previous hospitalization for limb ischemia were associated with increased risk for future amputation. CONCLUSION: The importance of preventing amputation in this population cannot be overemphasized. The strength of the association of amputation with PVD makes a strong case for screening all dialysis patients for this disease. The association of amputation with serum phosphorus level reported here should be explored further because this may offer an avenue for future intervention to reduce amputation rates.

Amputation, Surgical↗

PubMed2003

Decreased survival among sedentary patients undergoing dialysis: results from the dialysis morbidity and mortality study wave 2.

BACKGROUND: Sedentary behavior is associated with an increased risk for death in the general population. However, the association between inactivity and mortality has not been studied in a large cohort of dialysis patients despite the high prevalence of sedentary behavior in this group. METHODS: We used the Dialysis Morbidity and Mortality Study Wave 2, a prospective study of a national sample of 4,024 incident peritoneal dialysis and hemodialysis patients from 1996 to 1997, to determine whether sedentary behavior is associated with increased mortality during a 1-year period in this group after adjusting for confounding variables. RESULTS: The study population consisted of the 2,837 patients with accurate survival data who were able to ambulate and transfer. Eleven percent of the sedentary patients died during the study period compared with 5% of nonsedentary patients. In a survival analysis, sedentary behavior (hazard ratio, 1.62; 95% confidence interval, 1.16 to 2.27) was associated with an increased risk for death at 1 year after adjusting for all variables that we postulated might be associated with survival and for differences between sedentary and nonsedentary patients. CONCLUSION: Sedentary behavior is associated with an increased risk for mortality among dialysis patients similar in magnitude to that of other well-established risk factors, such as a one-point reduction in serum albumin concentration. More attention should be given to exercise behavior in dialysis patients, and controlled clinical trials are needed to further define the association of sedentary behavior with mortality.

Cardiovascular Diseases↗

PubMed2003

Prenatal screening for Down syndrome in England and Wales and population-based birth outcomes.

OBJECTIVE: Whether the introduction of antenatal screening for Down syndrome in England and Wales with serum biochemistry or ultrasound has led to improvements in patient outcomes is unknown. The purpose of this study was to relate pregnancy outcomes to the dominant method used for prenatal Down syndrome screening. STUDY DESIGN: For the years 1989 through 1999, England and Wales were divided into geographically defined areas where specific hospitals, health authorities, and cytogenetic laboratories provided maternity care for well-defined populations. For each year from 1989 through 1999, the dominant Down syndrome screening method that was used in each area was determined. Outcomes for area-years that used serum biochemistry or ultrasound (first or second trimester) were compared with area-years that used advanced maternal age as the dominant screening method. The percent of Down syndrome cases that were diagnosed prenatally (effectiveness) and the number of invasive prenatal tests that were performed to diagnose each Down syndrome case prenatally (efficiency) were compared. RESULTS: There were 5,980,519 births and 335,184 referrals for prenatal karyotyping (amniocentesis and chorionic villus sampling) that occurred in the area-years studied, of which 12,047 pregnancies were diagnosed as Down syndrome; 5393 cases of Down syndrome (45%) were diagnosed prenatally. Invasive testing increased from 4.4% of pregnancies in 1989 to 6.4% in 1997 and declined slightly in 1999 (5.8%). Prenatal diagnosis of Down syndrome cases rose from 28% in 1989 to 53% in 1999, and the number of invasive tests that were performed to diagnose each Down syndrome case fell from 89.7 to 47.7 (P [for trend]<.0001). Areas with serum or ultrasound as the dominant screening method detected 50% more Down syndrome cases in prenatally (52% and 53% vs 36%; P<.0001) and performed fewer invasive procedures to diagnose each Down syndrome case (60.7 and 52.0 vs 88.0; P<.0001) compared with areas in which advanced maternal age screening was dominant, despite serving populations with similar mean/median maternal ages. CONCLUSION: In clinical practice, screening programs for Down syndrome that were based on maternal serum biochemistry or ultrasound were more effective and efficient than the screening programs that used advanced maternal age alone.

Amniocentesis↗

PubMed2003

Prognostic significance of postoperative in-hospital complications in elderly patients. I. Long-term survival.

To determine the impact of in-hospital postoperative complications on long-term survival, we prospectively studied consecutive patients > or = 70 yr of age undergoing noncardiac surgery. Potential clinical risk factors were measured and evaluated for their association with the occurrence of long-term postoperative mortality. Long-term survival was determined by using the Kaplan-Meier method. Multivariate correlates of survival were analyzed with the Cox proportional hazards model. The survival of the study group was also compared with the age- and gender-matched general United States population. Five hundred seventeen patients who survived the initial hospitalization were studied. The mean follow-up duration was 28.6 +/- 12.8 mo. One hundred sixty-four of 517 patients (31.7%) were deceased at the time of follow-up. A history of cancer (hazard ratio [HR] 2.44, 95% confidence interval [CI] 1.78-3.38, P < 0.0001), ASA physical status >II (HR 2.27, 95% CI 1.61-3.21, P < 0.0001), neurologic disease (HR 1.59, 95% CI 1.13-2.24, P = 0.008), age (HR 1.42 per decade, 95% CI 1.11-1.81, P = 0.005), postoperative pulmonary complications (HR 2.41, 95% CI 1.30-4.48, P = 0.005), and renal complications (HR 6.07, 95% CI 2.23-16.52, P < 0.0001) were significant independent predictors of decreased long-term survival. Compared with the United States population, patients with complications had a greater increase in mortality risk in the first 3 mo after surgery (HR 7.3 versus general population) than those without complications (HR 2.9, P = 0.023). An effort to improve perioperative care delivery to elderly surgical patients must include measures to minimize in-hospital postoperative complications, particularly those involving the pulmonary and renal systems.

Age Factors↗

PubMed2003

Impact of renal insufficiency on short-term morbidity and mortality after lower extremity revascularization: data from the Department of Veterans Affairs' National Surgical Quality Improvement Program.

Few data are available on the impact of renal insufficiency on short-term operative outcomes after lower extremity surgical revascularization. We used prospectively collected data from the Department of Veterans Affairs' National Surgical Quality Improvement Program (NSQIP) to explore the association with renal dysfunction of adverse outcomes occurring within 30 d of lower extremity surgical revascularization in a cohort of all patients undergoing at least one lower extremity surgical revascularization from 1/1/94 to 9/30/01 (n = 18,217). Even moderate renal insufficiency (estimated GFR 30-59cc/min/1.73m(2)) was associated with an increased incidence of postoperative death (adjusted odds ratio (OR) 1.44, 95% confidence interval (CI), 1.17 to 1.77, P = 0.001), cardiac arrest (OR 1.43, CI 1.09 to 1.88, P = 0.011), myocardial infarction (OR 1.68, 1.39 to 2.16, P < 0.001), unplanned intubation (OR 1.69, CI 1.39 to 2.07, P < 0.001) and prolonged intubation (OR 1.57, CI 1.28 to 1.94, P < 0.001) within 30 d of lower extremity revascularization. However, the incidence of wound infection and graft failure requiring return to the operating room did not appear to be substantially higher in this group. Our data also show that patients with renal insufficiency undergoing revascularization were more likely to require distal procedures and to present with limb-threatening infection compared to those with normal renal function. Efforts to improve pre-and post-operative care in patients with renal insufficiency undergoing lower extremity revascularization should take into account the increased incidence of postoperative death and cardiopulmonary complications in this group in addition to more traditional concerns about operative site complications. Further studies are needed to explore reasons for the higher rate of limb-threatening infection in patients with renal insufficiency undergoing revascularization.

Acute Kidney Injury↗

PubMed2003

Age and variant Creutzfeldt-Jakob disease.

The young and stable median age of those who die of variant Creutzfeldt-Jakob disease has been attributed to age-dependent infection rates. This analysis shows that an influence of age on risk for death after infection better explains age patterns, suggesting that biologic factors peaking in the third decade of life may hasten disease.

Adult↗

PubMed2003

Adverse birth outcomes in relation to prenatal sonographic measurements of fetal size.

OBJECTIVE: To evaluate and quantify the prediction of multiple neonatal outcomes by sonographically estimated fetal weight across a broad range of gestational ages. METHODS: A retrospective cohortanalysis was conducted among women with certain gestational age (n = 1,376) seen at the University of California San Francisco from 1994 through 1997. The relative risks for small size at birth, small (low birth weight) for gestational age, and adverse neonatal outcomes were compared between small and average-sized fetuses. RESULTS: Fetuses with an estimated fetal weight in the 5th percentile or less for gestational age were at increased risk of a birth weight less than 2,000 g (relative risk, 6.5), a birth weight in less than the 3rd percentile for gestational age (relative risk, 10.1), preterm birth (relative risk, 2.2), extreme preterm birth (relative risk, 5.7), prolonged neonatal hospital stay (relative risk, 2.7), neonatal intensive care unit admission (relative risk, 3.2), and stillbirth or neonatal death (relative risk, 7.7) compared with average-sized fetuses (all P < .0001). With intrauterine growth restriction defined as an estimated fetal weight in the 5th percentile or less for gestational age, up to 29% of fetuses with adverse neonatal outcomes were detected, for false-positive rates of only 4% to 5%. After adjusting for confounding variables, low estimated fetal weight remained a significant predictor of neonatal morbidity and mortality. CONCLUSIONS: Morbidity and mortality are significantly increased among fetuses with an estimated fetal weight in the 5th percentile or less for gestational age.

Adult↗

PubMed2002

HIV-related neuropathology, 1985 to 1999: rising prevalence of HIV encephalopathy in the era of highly active antiretroviral therapy.

Postmortem neuropathologic reports for a consecutive series of 436 HIV-seropositive patients who died between 1985 and 1999 were matched with clinical data for 371 of them. Cases were divided into four groups depending on the date of death. The chosen time periods reflected the type of antiretroviral therapy available: before 1987 (before zidovudine); 1987-1992, the period of monotherapy (nucleoside analog reverse transcriptase inhibitors [NRTIs]); 1993-1995, the era of the use of dual NRTI combinations; and 1996-1999, the era of highly active antiretroviral therapy (HAART) containing protease inhibitors. Fifty-seven percent of our cases in this group had been prescribed HAART. In our study population, accessibility to the latest antiretroviral therapy was widespread. The total number of HIV autopsies declined after the advent of combination therapy. The prevalence of opportunistic infections-cytomegalovirus, toxoplasmosis, cryptococcosis, and central nervous system lymphoma-decreased over time. Cerebral tuberculosis, aspergillosis, herpes, and progressive multifocal leukoencephalopathy showed a downward trend, but the numbers were too low for statistical analyses. The incidence of HIV encephalopathy increased over time (p =.014). The rising prevalence of HIV encephalopathy at time of death may reflect a longer survival time after initial HIV infection in the HAART era. Although combination therapies decrease overall mortality and prevalence of CNS opportunistic infections, these therapies may be less active in preventing direct HIV-1 effects on the brain.

AIDS Dementia Complex↗