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Toward reducing pediatric injuries from firearms: charting a legislative and regulatory course.

Each year in the United States, approximately 3000 children and adolescents younger than age 20 die as a result of homicides, suicides, and unintentional injuries from firearms. The young children, relatives, neighbors, and friends of the 30,000 adults killed by firearms each year in the United States are also affected by this uniquely American epidemic. It is estimated that half of all American homes contain 200 million firearms, including 60 million handguns. Increasingly, pediatricians are becoming involved in efforts to reduce the prevalence of injuries from firearms, as parent educators, experts on children and adolescents, and advocates in the political process. This commentary is intended to aid in the last of these roles. The advocacy goal is identified as reducing the accessibility of guns in the environments of children and adolescents. The pros and cons of 17 possible approaches--ranging from mandatory safety courses in schools to handgun bans--are presented. It is concluded that, while there is no perfect approach, many available approaches will help; there is every reason to be both bold and optimistic.

Accident Prevention↗

[Is technical progress in the diagnosis of acute abdomen in daily practice fiction or reality? Analysis of 660 cases].

A clinical study of the cases of acute abdomen in 1970 and in 1980 has been conducted in two surgical departments (Zoug and Olten, Switzerland). In 660 cases the question was investigated whether progress has been made with the introduction of technical aids during the last ten years. In 1980 more specialized methods such as sonography, laparoscopy etc. were employed. Preoperative diagnosis was significantly improved and the agreement between pre- and postoperative diagnosis was markedly ameliorated.

Abdomen, Acute↗

[Intraoperative evaluation of surgical correction. Reconstructive interventions on the skeleton with ultrasound topometry].

We present a new 3 D analysis system which allows us to control axial correction in the skeletal system during operation. The method is based on the measurement of the transit time of ultrasound impulses from transmitters to receivers. With a gas sterilised digitiser we are able to record anatomical landmarks within a few seconds and with a high reliability. The results are reproducible with a precision of less than 1 mm. The duration of the whole measurement, including the positioning of the frame for the receivers and the computer aided data analysis, lasts 3 to 5 minutes. This technology enables us to analyse the 3 D body geometry and optimises operative procedures on the musculoskeletal system. Therefore, it is an addition to intraoperative x-ray control.

Anthropometry↗

Sex-ratio patterns of AIDS patients in Thailand.

The summary report of AIDS cases in Thailand, as of 31 July 1996, was reviewed for the information on male-to female sex-ratio. The ratios were recalculated for different risk-factors and for different age-groups annually and cumulatively. The male-to-female ratios calculated for annual case reports are lower than the cumulative number. This finding demonstrates the earlier detection of change in risk behaviour among the general population by the sex-ratio from annual case reports, compared to the ratio from the cumulative number of cases. Among different age-groups, the older age shows the highest male-to-female ratio. The ratio among sexually active age-group (15-49 years of age) is declining during the most recent year. These changes confirm the present pattern of AIDS epidemic in Thailand, the fourth wave among females, followed by the last wave-pediatric AIDS.

Acquired Immunodeficiency Syndrome↗

Long-term clinical observations on feline immunodeficiency virus infected asymptomatic carriers.

Eleven feline immunodeficiency virus (FIV) infected asymptomatic carrier (AC) cats were observed for 2 years for development of acquired immunodeficiency syndrome (AIDS). Four of the 11 (36.4%) showed progression of the clinical stage. Persistent generalized lymphadenopathy was noted in three cats as the first sign of illness after the AC phase, while the other showed lymphadenopathy with signs of AIDS-related complex. In all four cats the AIDS-related complex stage lasted for 10 months or longer, and two showed progression of the disease into AIDS. The two cats showing AIDS illnesses died within approximately 1 year after they had developed persistent generalized lymphadenopathy. Pathology confirmed the diagnosis of AIDS characterized by the presence of depletion lesions in the lymphoid organs, and of severe infections of an opportunistic nature. The overall mortality of FIV infected AC cats during a 2 year period was two out of 11 (18.2%). These cats showed decreased concanavalin A mitogen response of peripheral blood mononuclear cells as the disease progressed.

Animals↗

Seropositivity for HIV and the development of AIDS or AIDS related condition: three year follow up of the San Francisco General Hospital cohort.

The three year actuarial progression rate to the acquired immune deficiency syndrome (AIDS) in a cohort of men in San Francisco who were seropositive for the human immunodeficiency virus (HIV) was 22%. An additional 26 (19%) developed AIDS related conditions. Beta 2 Microglobulin concentration, packed cell volume, HIV p24 antigenaemia, and the proportion and number of T4 lymphocytes each independently predicted progression to AIDS. Beta 2 Microglobulin was the most powerful predictor. The 111 subjects tested who were normal by all predictors (40%) had a three year progression of 7%, and the 68 subjects who were abnormal by two or more predictors (24%) had a progression rate of 57%. Two thirds of all men who progressed to AIDS were in the last group. The median T4 lymphocyte count in subjects who did not progress to AIDS fell from 626 x 10(6) to 327 x 10(6)/l. HIV p24 antigenaemia developed in 7% of the subjects per year. The proportion who were abnormal by two or more predictive variables rose to 41%. At three years an estimated two thirds of the seropositive subjects showed clinical AIDS, an AIDS related condition, or laboratory results that were highly predictive of AIDS. It is concluded from the observed rates and the distribution of predictive variables at three years that half of the men who were seropositive for HIV will develop AIDS by six years after the start of the study, and three quarters will develop AIDS or an AIDS related condition.

AIDS-Related Complex↗

Improved survival for patients with AIDS-related Kaposi's sarcoma.

PURPOSE: We retrospectively analyzed all patients with AIDS-related Kaposi's sarcoma (AIDS-KS) seen at one large California medical center to delineate factors that may have contributed to a relative decline in survival. METHODS: Potential prognostic factors were analyzed individually, using the Cox proportional hazards regression model, for their association with survival. After a stepwise Cox regression procedure was applied to those factors that showed a significant effect on survival, a subset of factors that best predicted survival was identified. We then quantified the effect of the year of diagnosis on survival using a univariate Cox model. Next, we combined the year of diagnosis with the subset of prognostic factors previously identified into the Cox model to examine survival after adjustment for the prognostic factors. Survival distribution was estimated by the Kaplan-Meier method, and the 95% confidence interval for the median survival was computed using the modified reflected method. RESULTS: In 688 patients, we identified four baseline variables that best predicted survival: CD4 cell number, hematocrit, number of KS lesions, and body mass index (BMI). Adjusted for these predictive factors, there was a significant improvement in survival for patients with AIDS-KS over the last 6 years. CONCLUSION: Contrary to prior reports, survival has increased for patients with AIDS-KS. The apparent increase in observed mortality is most likely due to a decline in the CD4 cell number at presentation.

Acquired Immunodeficiency Syndrome↗

Survival of European patients with Kaposi's sarcoma as AIDS-defining condition during the first decade of AIDS. AIDS in Europe Study Group.

OBJECTIVES: To determine whether the survival of patients with Kaposi's sarcoma as first manifestation of AIDS has changed between 1979 and 1989; and to define whether prognosis factors could be identified. PATIENTS AND METHODS: This is a multicentric retrospective cohort study from 52 centers in 17 European countries involving adults AIDS patients diagnosed between 1979 and 1989. Variables such as age, sex, geographical regions, transmission groups, date of Kaposi's sarcoma diagnosis, zidovudine use, CD4+ cell count and concomitant opportunistic infections or AIDS-related malignancies were evaluated by using uni- and multivariable proportional hazard models. Log-rank tests were used to determine which variables were associated with survival. RESULTS: From the 6,546 AIDS patients recruited in the database of the AIDS in Europe Study Group, 1,394 were diagnosed with Kaposi's sarcoma at the time of AIDS diagnosis, from 1979 and 1989. A total of 1,047 Kaposi's sarcoma patients died during the follow-up period. By Kaplan-Meier analyses, the median and mean survival for these Kaposi's sarcoma patients were 17 and 25 months, respectively, with no change over time. However, age, sex (female), geographic region, low CD4+ cell count (< 150 x 10(6)/l) and some opportunistic infections and non-Hodgkin's lymphoma were associated with a poorer prognosis. Zidovudine use, year of diagnosis and risk factor for HIV-1 infection brought no additional information as predictor of mortality. CONCLUSIONS: This study suggests that the survival of patients with Kaposi's sarcoma as first manifestation of AIDS has remained poor during the last decade in contrast with the overall AIDS survival which had significantly improved from a median of 13-18 months during the same period of observation. There is a need for further prospective information to explain the worse prognosis in women and the geographical variations.

AIDS-Related Opportunistic Infections↗

Premature mortality related to AIDS among men and women in Catalonia.

OBJECTIVES: To evaluate the mortality pattern observed in relation to the AIDS epidemic, and to estimate the current and future demographic impact of AIDS among the population aged between 20 and 39 years in Catalonia, Spain. DESIGN: Spain has the highest cumulative incidence rate of AIDS in Europe. One-third of Spanish AIDS cases have been consistently reported from Catalonia, an autonomous region in northeastern Spain with a population of 6 million, and with Pattern I HIV transmission. In this study data from the population-based AIDS registry and death certificates in Catalonia were used. METHODS: Since 1981 AIDS data have been collected routinely from all hospitals using an active surveillance system. All causes of death are coded from death certificates (ICD-9). Mortality rates since 1981 were analysed by age and sex. To assess the relative importance of premature mortality due to AIDS, years of potential life lost (YPLL) before age 65 were used. RESULTS: Since 1982 there has been a continuous increase in crude mortality rates, particularly significant for men aged 20-39 years after 1986 (F < 0.001). While AIDS was the fourth most likely cause of death among people aged 20-39 years in 1988, by 1991 it was the second most likely. In 1990 AIDS contributed to 13,213 YPLL (8.7%) for men and 2579 YPLL (4%) for women. During the last few years AIDS-related deaths have had the highest mortality rate progression among young adults. CONCLUSION: According to the current available data, AIDS might become the leading cause of death for the population aged 20-39 years in the near future. AIDS is having an important impact on the demography of European countries with Pattern I transmission and high HIV prevalence rates.

Acquired Immunodeficiency Syndrome↗

Thiamine deficiency and Wernicke's encephalopathy in AIDS.

Several neuropathological reports in the last 5 years have described brain lesions characteristic of Wernicke's Encephalopathy in patients with AIDS. Using the erythrocyte transketolase activation assay, we now report biochemical evidence of thiamine deficiency in 9/39 (23%) of patients with AIDS or AIDS-related complex. In no cases was there history of alcohol abuse nor were there clinical signs of Wernicke's Encephalopathy. Thiamine deficiency in these patients most likely results from the cachexia and catabolic state characteristic of AIDS. In view of (i) the confirmed neuropathological evidence of Wernicke's Encephalopathy in AIDS patients, (ii) the significant thiamine deficiency in these patients and (iii) the difficulties of clinical diagnosis of Wernicke's Encephalopathy, it is recommended that dietary thiamine supplementation be initiated in all newly diagnosed cases of AIDS or AIDS-related complex.

AIDS-Related Complex↗

International inequities dent concept of common front against HIV.

This is the last in a series of articles about the XI International AIDS Conference field in Vancouver last summer. Much of the news from the conference dealt with positive developments surrounding scientific advances, but delegates also heard a call for a more united world effort against HIV.

Adult↗

Development of the membranous labyrinth of human embryos and fetuses using computer aided 3D-reconstruction.

The last detailed description of the development of the inner ear membranous labyrinth goes back to Streeter in 1918. This investigation can be regarded to be of outstanding scientific value. However, at that time no staging system of human embryos existed. In this respect, Streeter's work is outdated. It was the aim of this study to reinvestigate the development of the membranous labyrinth in human embryos and fetuses of which the developmental stages have been determined according to the Carnegie staging system and to compare the results with the literature. Serial histologic sections in the coronal or frontal plane of the heads of human embryos and fetuses of different developmental stages were used for computer aided 3D-reconstruction of the membranous labyrinth. From the obtained results, it is concluded that the endolymphatic duct develops earlier than previously described in the literature. The induction of the differentiation of the endolymphatic duct does not correspond with the superficial ectoderm because the endolymphatic duct develops medial of the otic vesicle. The membranous labyrinth determines the form of the petrosal bone as early as in stage 19 (47-48 days post conception).

Ear, Inner↗

Mycobacterium avium complex: advances in therapy.

Disseminated Mycobacterium avium complex (MAC) is one of the most common opportunistic infections in AIDS patients and is increasingly recognized as a significant pathogen in chronic pulmonary disease in nonimmunocompromised patients. Important progress in therapy has occurred over the last several years. In AIDS patients, multidrug therapy has been shown to be beneficial in terms of reducing circulating bacteremia and improving clinical symptoms. Clarithromycin and azithromycin, two broad-spectrum antimicrobials with minimal activity against Mycobacterium tuberculosis, have emerged as potent, well tolerated agents pivotal to treatment regimens. In AIDS patients, rifabutin prophylaxis reduced the frequency of MAC bacteremia by 50% in two placebo controlled trials. Despite these advances, there remains a need for determining the optimal combination regimens for therapy, and more effective drugs for prophylaxis which are beneficial both in terms of survival and functional capacity of patients.

AIDS-Related Opportunistic Infections↗

Health care workers' anxieties and fears concerning AIDS: a literature review.

Acquired immunodeficiency syndrome (AIDS) is a serious illness and a public health crisis that merits the concern of everyone. Three key features make AIDS difficult to control. The first feature is that the disease is predominantly spread sexually. The second feature is that a period of infectivity may last from months to years, and the infected individual may not be aware that he or she is infected. The last feature is that AIDS also may be spread by percutaneous and perinatal transmission. Whatever success public education may have in changing sexual behavior, it will not be seen for several years, and the number of AIDS cases will continue to grow. The following literature review leads to a prediction that education will have a profound impact on the anxiety connected with providing care for AIDS patients. Education is a powerful tool that can be used by health care workers to change how AIDS is perceived. Health care workers must become aware of their misconceptions, fears, and anxieties about this disease and afflicted individuals.

Acquired Immunodeficiency Syndrome↗

[Impact of AIDS on admissions and mortality in an Internal Medicine Department (1990-1995)].

OBJECTIVE: To know and analyze the main causes of death in an Internal Medicine Department (MI), as well as the impact of AIDS on admissions and mortality rate in such a Department. MATERIALS AND METHODS: A total of 275 patients out of the 35,521 attended patients from 1990 to 1995 had positive serology to HIV (HIV+). A total of 1,793 deaths were recorded, 42 of which were attributed to AIDS. Clinical and epidemiologic parameters were studied; also, management parameters associated with death were investigated (particularly, those caused by this disease). RESULTS: The overall mortality rate was 5.04%, where as the mortality rate among HIV+ in patients was 15.27%; the primary causes of death were cardiovascular, tumoral, and respiratory disease by decreasing frequency. AIDS was the first cause of death in patients aged less than 35 years. As for AIDS, the number of admissions on account of this disease had a progressive increase along the study period; the mean age of dead patients (31.6 years) tended to increase in the last few years and to be significantly higher among men (6 years); the mean of hospital stay among HIV+ patients (14.16 days) tended to decrease in the last few years. CONCLUSIONS: AIDS has had a progressive increase and has become the primary cause of hospital death in IM, in patients aged less than 35 years. As the experience with this disease increases, the mean stay of HIV+ patients decreases, although it tends to increase in patients who ultimately die, possibly because of the social changes in the last few years, as disease, and particularly death, is intended to become separated from family home.

Acquired Immunodeficiency Syndrome↗

Characteristics of acquired immunodeficiency syndrome in older adults.

OBJECTIVE: To examine demographic and clinical features of older AIDS patients in comparison with younger individuals. DESIGN: Data base review. SETTING: Maryland AIDS Registry from 1981 through the end of 1994. PARTICIPANTS: All registered Maryland AIDS cases greater than or equal to 60 years of age at diagnosis and all Maryland AIDS cases aged 20 to 39. MAIN OUTCOME MEASURES: Demographic features, mode of transmission and change in mode over time, clinical presentations, CD4+ counts, and survival time. RESULTS: A total of 321 (2.7%) AIDS cases diagnosed in Maryland were people 60 years of age or older compared with 7511 cases (63.9%) in people aged 20 to 39 years. The proportion of whites was higher in the older group, but the gender distribution was similar to younger counterparts. Transfusion was the primary cause of exposure of 32% of the older people with AIDS; however, during the last few years, sexual transmission and drug abuse have been implicated more frequently. Twelve percent of older patients had no reported risk factors compared with 4% of younger AIDS patients. The most common presenting AIDS indicator disease in older cases was Pneumocystis carinii pneumonia. Wasting syndrome, candidiasis, and HIV encephalopathy also occurred frequently. Median life span was 9 months compared with 22 months in the young. CONCLUSION: Our study demonstrates that transfusion is no longer the leading cause of AIDS in older people in Maryland. The relatively increased prominence of transmission by other modes in this age group raises the importance of preventive and educational measures. Older patients generally have a shorter survival than younger individuals.

Acquired Immunodeficiency Syndrome↗

[HIV, AIDS and ethics].

The epidemic spread of HIV infections and the AIDS disease in the last two decades of the 20th century has quite unexpectedly confronted European civilization, including North America, with a great number of ethical problems. Today, two decades after the first signs of AIDS' possibly epidemic threat not only to individual regions but to the entire population of the world, we can already answer the questions whether Western society has learned from the past and whether the concern for the rights of the individual and of groups previously discriminated in one way or another (a concern increasing since the 1950 s initially in the USA and then in Europe) has led to a more sensitive stance in dealing with victims of the HIV and AIDS epidemic. In Europe and North America, after initial unrest and occasionally exaggerated reactions, the confrontation with HIV infection and AIDS has mostly shown a marked improvement over the way epidemics and their victims were dealt with in earlier centuries. A substantial difference from earlier epidemics is that the understandable temptation to identify the disease with a specific group of persons has meanwhile been overcome; instead of collectively discriminating against people whose style of life substantially contributes to the spread of the disease, the focus of investigation is on behaviors; increasingly, the actors are not mentioned. There is probably no other disease that touches upon a comparably broad spectrum of ethical principles. HIV infection and the AIDS disease provide models for evaluating almost all basic ethical principles that can find application in a medical context. From the identification of those infected, the search for an effective therapy, the treatment of the diseased, to the compassion with the dying and in many other respects a historically unprecedented degree of taking into regard the interests of groups at risk and of those affected have been taken into account. It is in view of the global dimension of the HIV/AIDS epidemic that a second challenge confronts European civilisation. Here the formulation of relevant politics has not been (and is unlikely to be) influenced by emotions or an abstract morale. Rather, it has been a recognition of a self-interest of Western nations vis-a-vis a possible scenario of a breakdown of public order and democratic structures in some parts of the world that has brought about a reorientation. Increasingly, the resources of governments, of science, and of private enterprise of Western nations are brought together to match the needs of those non-Western countries where the HIV/AIDS epidemic has reached catastrophic dimensions. It may well be that these efforts will support the development of vaccines and therapies affordable in these countries.

Acquired Immunodeficiency Syndrome↗

[Knowledge of high school students about HIV and AIDS].

In 475 students attending the last school year in four high schools in the town of Povazská Bystrica, Slovakia a questionnaire survey of students' knowledge of HIV infection and AIDS was carried out. 76.33% of all answers to questions in the questionnaire were correct. We found no significant differences between the percentage of correct answers among schools, among boys and girls and among students living in the country and in town. 56% of the students fought that there is enough information about HIV infection, AIDS and about prevention of that infection. Nevertheless the percentage of correct answers to some questions in the questionnaire do not correspond to this statement.

Acquired Immunodeficiency Syndrome↗