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Issues of women dually diagnosed with HIV infection and substance use problems in the Carolinas.

A growing number of women are being dually diagnosed with HIV infection and substance use problems. Forty-two percent of all women diagnosed with AIDS have been infected through injection drug use. Many more women with HIV are exposed to nonintravenous drugs that potentially affect their quality of life and illness experience. This study sought to identify from the perspective of women factors that most influenced their ability to obtain treatment for their HIV infection and control their substance use. A focus group approach was used for data collection. Twenty-five HIV-infected women participated in one of four focus groups. Women were asked to identify and discuss their concerns and needs related to HIV/AIDS and substance use. Twenty-four women were African-American; one was white. All the women reside in South Carolina or North Carolina. Each focus group session was audiotaped and transcribed. Content analysis, following Krippendorff's (1980) methodology, was used to analyze the data. Five themes emerged: 1) AIDS as a life-altering event; 2) spirituality; 3) mental health issues; 4) barriers to health care services; and 5) environmental influences. It was concluded that the coexistence of HIV and substance abuse adds to the complexity of women's treatment needs. For these women, an HIV diagnosis can serve to alter their lives either positively or negatively. Dually diagnosed women have unique needs that require integration of physical and psychosocial interventions. These women may benefit from the services of psychiatric or mental health nurse practitioners who have the skills necessary to address the many psychosocial issues women face as well as provide physical treatment. Additionally, drug treatment services need to be expanded and made more comprehensive. Drug treatment programs need to be developed specifically for women, and these services need to be made accessible to poor women with substance abuse problems. Further, drug treatment programs need to provide comprehensive services that can appropriately integrate the treatment of HIV disease and substance abuse.

Adult↗

PubMed1994

Predictors of chronic "postviral" fatigue.

We set out to determine the relation between a general practitioner (GP) diagnosis of viral illness and development of chronic fatigue 6 months later. 618 subjects who attended GPs clinics in London, south, and southwest England and who received a diagnosis of viral illness were followed prospectively and fatigue was assessed by questionnaire after 6 months. At presentation, GPs recorded fatigue in 62.6% of subjects, usually since the onset of symptoms. 502 (81.2%) subjects completed the 6-month questionnaire, of whom 88 (17.5%) met criteria for chronic fatigue and 65 (12.9%) had no reported fatigue before the viral illness. Compared with a similar group of non-postviral GP attenders, the risk ratio for chronic fatigue in the present cohort was 1.45 (95% CI 1.14-2.04). Infective symptoms did not predict fatigue 6 months later. Psychiatric morbidity, belief in vulnerability to viruses, and attributional style at initial presentation were all associated with self-designated postviral fatigue. Logistic regression showed that somatic attributional style, less definite diagnosis by the GP, and sick certification were the only significant predictors of chronic fatigue after viral infection when other factors were controlled for. Chronic severe fatigue 6 months after GP-diagnosed viral illness is related to symptom-attributional style and doctor behaviour, rather than to features of the viral illness. Some subjects with apparent postviral fatigue had complained of tiredness before their presentation with a viral illness.

Adult↗

PubMed1998

How might general practitioner knowledge of patient Helicobacter pylori status change the management of dyspepsia in primary care?

BACKGROUND: Recent guidelines have suggested that testing young dyspeptic patients for Helicobacter pylori infection will produce more appropriate referrals for endoscopic investigation. Our aim was to describe how awareness of patient H. pylori status changes the practice of general practitioners (GPs) who do not currently use H. pylori testing and/or eradication in their management of dyspepsia. We studied a 5 per cent systematic sample (n = 177), stratified by health authority, of GPs in the North West region of England. METHODS: A questionnaire-based assessment of self-reported practice of young patients with dyspepsia was carried out. RESULTS: Over three-quarters of GPs would choose eradication therapy rather than ulcer healing drugs if they knew the patient was positive for H. pylori infection. Twenty-nine per cent of GPs would refer for endoscopy when the patient's H. pylori status was unknown, 32 per cent when it was positive, and 22 per cent when it was negative. However, GPs responded in an inconsistent manner to knowledge of patient H. pylori status. Some chose to refer positive patients only, others only patients with negative status, and a minority would refer both positive and negative patients. CONCLUSIONS: Until the use of H. pylori tests in primary care populations has been evaluated in appropriate prospective randomized controlled trials, advocates of testing as a means to reduce endoscopy referrals should be cautious about its potential impact on service workload.

Clinical Competence↗

PubMed1983

Gonorrhea.

The gonococcus has become an extremely important organism in obstetrics and gynecology. It is associated with a wide array of clinical syndromes that frequently confront the practitioner. The diagnostic modalities available are many and are rapidly increasing. Therapy likewise is becoming complex as we learn more about the infections associated with this microbe. The basic principles of care still include a high index of suspicion of infection; clinical evaluation of the potentially infected patients; laboratory support of the clinical diagnosis; specifically directed antimicrobial therapy of adequate dosage and duration; treatment of sexual partners; and follow-up test-of-cure evaluation in all patients.

Adolescent↗

PubMed1996

Sputum gram's stain in community-acquired pneumococcal pneumonia. A meta-analysis.

The usefulness of the sputum Gram's stain is controversial. This meta-analysis was designed to evaluate the sensitivity and specificity of the sputum Gram's stain in community-acquired pneumococcal pneumonia. Using a predetermined protocol, articles were discovered through a MEDLINE search (1966 to 1993) and the examination of bibliographies and were graded for quality by three blinded reviewers. Information on the reference standard, blinding, stain interpreter, control for antibiotic use, and definition of a positive test was collected. We found 12 articles containing 17 test characteristics to evaluate. The number of patients in each study ranged from 16 to 404. Sputum culture was the most common reference standard (10 of 17 estimations). Sensitivity ranged from 15% to 100% and specificity from 11% to 100%. Test characteristics varied markedly among studies and appeared related partly to the test interpreter. The sputum Gram's stain may yield misleading results in community-acquired pneumonia, as its sensitivity and specificity vary substantially in different settings. A practitioner electing to use the study should be well trained and use a specific definition for a positive test.

Community-Acquired Infections↗

PubMed1992

Suspended judgment. AIDS and the ethics of clinical trials: learning the right lessons.

There is a tribe of thinkers who believe that new technological advances and scientific discoveries raise new ethical issues. And it is the case, of course, that scientific and technological change--change in knowledge and power--implies a new realm for choice and, therefore, moral reflection. In the case presently concerning us, they see the AIDS social and scientific crisis as requiring the adoption of new ethical principles. I believe to the contrary. AIDS--more broadly, the entire spectrum of HIV disease--does not in itself present radically new issues at the level of principle. For example, the questions associated with confidentiality and HIV disease that have to this point dominated public discourse about morality and AIDS simply resurrect old questions raised by potentially deadly infectious disease. Recent discussions of the ethical issues associated with HIV-infectious health care workers fail to recognize that HIV is simply a new garb for the old question of the impaired or unsafe practitioner. HIV disease does have this effect on ethical reflection, however: It rubs our noses in issues that may have received insufficient attention to date. The urgency and poignancy associated with moral conflict and HIV disease forces us to face up to questions hitherto ignored. But this may be a good or a bd thing. In the heat of crisis, being human, we are likely to call for change without adequate consideration of the need for and effects of that change.(ABSTRACT TRUNCATED AT 250 WORDS)

Acquired Immunodeficiency Syndrome↗

PubMed2001

Key issues in developing antibiotic policies: from an institutional level to Europe-wide. European Study Group on Antibiotic Policy (ESGAP), Subgroup III.

Establishment of a rational antibiotic policy (RAP) is a key issue for both better care of patients and combating antimicrobial resistance [1-5]. The problem of rational antibiotic use is complex [6,7] and requires co-ordination of the activities of healthcare authorities, institutions and individual practitioners. Furthermore, on a community basis, it involves restriction of non-human usage of antibiotics [8] and awareness of society about both the useful and harmful effects of antibiotics [9] and, on a national basis, participation of governmental [10] and non-governmental [11] organizations in collaboration with European and international medical societies [12-14]. The rational use of antibiotics should be established in both hospital and ambulatory settings [10]. Institutional, regional, national and global aspects of antibiotic policies should be considered [2].

Anti-Bacterial Agents↗

PubMed2005

[When should a stool culture be done in adults with nosocomial diarrhea?].

OBJECTIVE: To assess the diagnostic efficacy, cost and possible corrective measure of the indications for routine stool cultures in nosocomial diarrhoea in adults. METHODS: A retrospective study over a 10-month period of 660 standard stool cultures, 256 of which were conducted after the 3rd day of hospitalisation, conducted in 528 patients at the hospital centre in Pau. RESULTS: The positivity rate of the stool cultures was of 26/336 patients (7.7%), and of 37/404 examinations (9%) within the first three days of hospitalisation, versus 2/192 patients (1%) and 3/256 examinations (1%) after the 3rd day of hospitalisation (p<0.05). In 83 patients a stool culture was repeated, and was only positive in one patient with an initially negative culture. If a stool culture had not been performed after the 3rd day, 2 infections would not have been diagnosed (1 salmonella and 1 K. oxytoca) and 256 stool cultures could have been economised (estimated cost: 6,144 euro). Moreover, by eliminating repeated stool cultures, 3 infections would not have been diagnosed (2 salmonella, and 1 K. oxytoca) and 321 stool cultures would have been avoided (estimated cost: 7,704 euro). If the stool cultures had been conducted after the 3rd day of hospitalisation only in those aged over 64 with comorbidity, immunosuppression or within the context of an epidemic, no false negative would have been observed and 149 stool cultures would have been economised (estimated cost: 3,576 euro). The positivity rate of the search for C. difficile, only conducted on explicit request from the practitioners, was of 5/23 (22%) and 4/28 (14%) before and after the 3rd day of hospitalisation (non-significant difference). CONCLUSION: Restriction of standard stool cultures after the 3rd day of hospitalisation to patients aged over 64 with comorbidity, to the immunodepressed, and within an epidemic context would economise around 4,300 euro per month in a medium-sized general hospital. No systematic restriction should be applied to the search for C. difficile.

Adult↗

PubMed1994

A prospective case-control study of antibodies to coxsackie B virus in idiopathic dilated cardiomyopathy.

OBJECTIVES: This study was conducted to determine the frequency and significance of Coxsackie B virus-specific immunoglobulin-M (IgM) in patients with idiopathic dilated cardiomyopathy and compare them with the frequency in both unmatched and matched control subjects. BACKGROUND: The principal evidence supporting a pathoetiologic role for Coxsackie B viruses in human dilated cardiomyopathy is derived from retrospective serologic studies. These studies have evaluated patients with end-stage disease and have failed to recognize the importance of assessing both matched and unmatched control subjects. METHODS: In this prospective case-control study, we assessed sera for Coxsackie B virus-specific IgM (serotypes B1 to B5) from 114 patients with dilated cardiomyopathy at diagnosis or referral to our center, 94 healthy unmatched control subjects, 41 healthy matched control subjects from the same general practitioner and 32 members of the patients' own households. RESULTS: A higher frequency of positive Coxsackie B virus IgM was observed in patients with dilated cardiomyopathy than in unmatched control subjects (33% vs. 5%; p = 3 x 10(-7)). In patients with dilated cardiomyopathy, the response was monotypic (84%), commonly against serotypes B2 and B5, and was not associated with any clinical or histologic feature. The frequency of positive virus-specific IgM was similar in patients with dilated cardiomyopathy and their 41 matched community control subjects (46% vs. 27%; p = 0.11) and 32 household contacts (37% vs. 28%; p = 0.59). Control subjects who tested positive for virus-specific IgM tended more commonly to be seropositive than did control seronegative subjects (community control subjects 37% vs. 18%, p = 0.32; household contacts 42% vs. 20%; p = 0.36) and had an identical serotypic response in 4 (33%) of 12 cases. CONCLUSIONS: The frequency of Coxsackie B virus IgM was higher in patients with dilated cardiomyopathy than in unmatched control subjects but was similar in patients and control subjects who shared the same environment, indicating local spread of infection. The reason for the association between Coxsackie B virus IgM and dilated cardiomyopathy and its relevance to pathogenesis remain to be established.

Adult↗

PubMed1995

Psychological response to HIV positivity in hemophilia.

OBJECTIVE: To compare the psychological and family adaptation of children and adolescents with hemophilia who were seropositive for human immunodeficiency virus type 1 (HIV-1) with an HIV-negative group of comparable age, demographic characteristics, and disease severity in a multi-site study. DESIGN: Cross-sectional, controlled study. SETTING: Thirty-three hemophilia treatment centers throughout the United States. SAMPLE: Ninety-one children and adolescents with hemophilia who were seropositive for HIV and 92 children and adolescents with hemophilia who were seronegative and of comparable age, demographic characteristics, and disease severity. RESULTS: HIV-seropositive children and adolescents reported less positive affect [(lower well being) (P < .05)], and more frequent hemophilia-related school absences were identified among HIV-infected patients (P < .005). However, the two groups demonstrated surprisingly comparable levels of psychological, social, hemophilia-related adjustment, general family relations, and hemophilia-related family adaptation, as reported by patients and parents. However, mothers of HIV-seropositive children and adolescents reported higher levels of general psychological distress (P < .008) and higher levels of distress related to hemophilia (P < .0002) than parents of HIV-negative children. CONCLUSIONS: Seropositive children and adolescents with hemophilia demonstrate psychological resilience and levels of psychological adjustment that were comparable to seronegative counterparts. However, mothers of seropositive children were more distressed than mothers of HIV-negative children. Practitioners should ensure that stressed mothers obtain necessary psychological support.

Adaptation, Psychological↗

PubMed2004

Comparison of private for-profit with private community-governed not-for-profit primary care services in New Zealand.

OBJECTIVE: To compare the characteristics of patients, their disease patterns, and the investigation and referral patterns in private community-governed not-for-profit and private for-profit primary care practices in New Zealand. METHODS: Observational study using a representative survey of visits to general practitioners in New Zealand. Practices were categorised according to their ownership: private for-profit or private community-governed not-for-profit. Patient socio-demographic characteristics, treated prevalence and other characteristics of presenting problems, morbidity burden, numbers of investigations and referral patterns were compared. RESULTS: Compared with for-profit practices, community-governed not-for-profit practices served a younger, largely non-European population, nearly three-quarters of whom had a means-tested benefit card (community services card), 10.5% of whom were not fluent in English, and the majority of whom lived in the 20% of areas ranked as the most deprived (by the NZDep2001 index of socio-economic deprivation). Patients visiting not-for-profit practices were diagnosed with more problems, including higher rates of asthma, diabetes and skin infections, but lower rates of chest infections. The duration of visits was also significantly longer. No differences were observed in the average number of laboratory tests ordered. The odds of specialist referral were higher in for-profit patients when confounding variables were controlled for. CONCLUSIONS: Community-governed not-for-profit practices in New Zealand serve a poor, largely non-European population who present with somewhat different rates of various problems compared with patients at for-profit practices. The study highlights for communities, policy-makers and purchasers the importance of community-governed not-for-profit practices in meeting the needs of low-income and minority population groups.

Adolescent↗

PubMed2006

Detection of human coronavirus NL63, human metapneumovirus and respiratory syncytial virus in children with respiratory tract infections in south-west Sweden.

Two recently detected viruses, human metapneumovirus (hMPV) and coronavirus NL63 (HCoV-NL63), have been associated with acute respiratory tract infections, particularly in young children. This study investigated the frequency of hMPV and HCoV-NL63 infections in Swedish children by screening 221 nasopharyngeal aspirates, collected between November 2003 and May 2005, from 212 children attending the paediatric department of a county hospital in Sweden or submitted from local general practitioners. The samples were originally submitted to be tested for respiratory syncytial virus (RSV), and were examined retrospectively for hMPV and HCoV-NL63 by RT-PCR. Of the 212 patients, 101 were positive for RSV (48%), 22 (10%) were positive for hMPV, and 12 (6%) were positive for HCoV-NL63. The frequency of HCoV-NL63 infection increased from 1% in 2003-2004 to 10% in 2004-2005. Sequence analysis of parts of the coronavirus genomes showed considerable similarity to the HCoV-NL63 prototype sequence. The study demonstrated that HCoV-NL63 and hMPV occur in south-west Sweden with essentially the same frequency, seasonal distribution and clinical characteristics as have been reported in other countries.

Acute Disease↗

PubMed1983

Oral bacterial flora and secretory IgA in small children after repeated courses of antibiotics.

23 small children with recurrent respiratory tract infections, who were found to have low saliva IgA levels but normal serum Ig levels, were divided into two groups: group 1 (12 patients) in whom antibiotics were stopped for a period of 18 months, and group 2 (11 patients) who received antibiotics when necessary for an equal period of time. Parents of group 1 children were instructed to bring their children to our department on signs of respiratory tract infections with fever, whereas group 2 children were treated by their general practitioner. At the termination of the study, contrary to group 2 children, most group 1 children had developed normal saliva IgA levels, carried few potentially pathogenic bacteria in their throats, and had received considerably fewer courses of antibiotics. The question is raised, whether repeated antibiotic therapy in small children favours the colonization of pathogenic bacteria on mucosal surfaces, and, whether proteases, synthesized by these microorganisms may be able to cleave IgA in secretions.

Anti-Bacterial Agents↗

PubMed1999

Quantification of the transmission of classical swine fever virus between herds during the 1997-1998 epidemic in The Netherlands.

In this study, we describe a method to quantify the transmission of Classical Swine Fever Virus (CSFV) between herds from data collected during the 1997-1998 epidemic in The Netherlands. From the contacts between infected herds and the serological findings shortly before depopulation, we estimated the week of virus introduction and the length of the period over which the herd emitted virus for each CSFV-infected herd. From these data, we estimated the infection-rate parameter beta (the average number of herds infected by one infectious herd during one week) and the herd reproduction ratio, Rh (the average total number of secondary outbreaks caused by one infectious herd, i.e. in its entire infectious period), using a SIR-model for different sets of CSF control measures. When Rh > 1, an epidemic continues to grow. On the other hand, when Rh < 1 an epidemic will fade out. During the phase before the first outbreak was diagnosed and no specific measures had been implemented, beta was estimated at 1.09 and Rh at 6.8. In the subsequent phase infected herds were depopulated, movement restrictions were implemented, infected herds were traced forward and backward and the herds in the protection and surveillance zones were clinically inspected by the veterinary authorities (regional screening). This set of measures significantly reduced beta to 0.38. However, Rh was 1.3 and thus still > 1. Consequently, the number of outbreaks continued to grow. After a number of additional measures were implemented, the value of Rh was reduced to 0.5 and the epidemic came to an end. These measures included pre-emptive slaughter of herds that had been in contact with infected herds or were located near an infected herd, increased hygienic procedures, replacement of transports of pigs for welfare reasons by killing of young piglets and a breeding ban, and regional screening for CSF-infected herds by local veterinary practitioners.

Animal Husbandry↗

PubMed1988

Rational decisions in managing sore throat: evaluation of a rapid test.

Sixty nine general practitioners recorded what they had prescribed for a total of 1189 episodes of sore throat. Antibiotics were prescribed in 763 (64%) episodes and broad spectrum antibiotics in 161 (21%) of these. If there was dysphagia, hoarseness, cervical adenopathy, and inflamed or purulent tonsils a prescription was more likely to be written. An enzyme immunoassay rapid test was evaluated as a means of rationalizing prescribing. Among 23 general practitioners and 250 patients the sensitivity of the test was 63% and the specificity 91.7% compared with 74% and 58% for clinical assessment alone. Test results rarely caused previous prescribing decisions (34 [corrected] (13%) episodes) to be altered. We suggest that the time is not ripe for the use of the enzyme immunoassay rapid test on a wide scale in the routine assessment of sore throats.

Anti-Bacterial Agents↗

PubMed2003

The study of infectious intestinal disease in England: what risk factors for presentation to general practice tell us about potential for selection bias in case-control studies of reported cases of diarrhoea.

BACKGROUND: Cases reported to national surveillance systems commonly form the sampling frame for population-based case-control studies of infectious intestinal diseases (IID). However, reported cases represent a minority of all cases in the population, differ systematically from unreported cases, and their use in case-control studies could introduce biases. Case reporting is a selective process involving multiple stages, the first of which requires presentation by a symptomatic person to the health services. Factors affecting a person's likelihood of presentation will thus affect the characteristics of reported cases. METHODS: Data from a large study of IID in England were used to investigate factors influencing presentation to a general practitioner (GP) following an episode of IID. Multivariable logistic regression was performed, comparing GP presenters with non-presenters. Explanatory variables used were illness severity, recent foreign travel and socioeconomic indicators. RESULTS: Severe illness (OR = 12.54, 95% CI: 7.58-20.74), recent foreign travel (OR = 2.4, 95% CI: 1.39-4.14), leaving full-time education at an earlier age (OR = 2.06, 95% CI: 1.22-3.50) and housing categories representing lower socioeconomic status (SES) were all independently associated with GP presentation. CONCLUSIONS: Case reporting to national surveillance is shaped by complex biological and social factors, of which illness severity appears to be the most important. Results from case-control studies comparing cases of IID identified by surveillance with population controls are likely to generalize mainly to cases severe enough to be reported. Controlling for educational and SES (mostly housing) is required.

Acute Disease↗

PubMed1980

Doxycycline and amoxycillin in respiratory infections: a comparative assessment in general practice.

A general practitioner survey was carried out to compare the efficacy of doxycycline and amoxycillin in the treatment of 267 patients with respiratory tract infections requiring antibiotic therapy. The findings, based on clinical observations, suggest that both antibiotics were equally effective in providing prompt improvement and complete resolution of the infection, only 7 of the 134 receiving doxycycline and 13 of the 133 patients receiving amoxycillin failing to show a satisfactory response. There was a statistically significant better response in those patients with acute and acute-on-chronic bronchitis who were treated with doxycycline. It is possible that this may have been related to a local upsurge in mycoplasma infection at the time of the study.

Adolescent↗

PubMed2004

Economic evaluation of Helicobacter pylori eradication in the CADET-Hp randomized controlled trial of H. pylori-positive primary care patients with uninvestigated dyspepsia.

BACKGROUND: Adult Helicobacter pylori-positive patients by 13C-urea breath test with uninvestigated dyspepsia symptoms were randomized to 1-week eradication treatment with omeprazole, metronidazole and clarithromycin (OMC) vs. omeprazole and placebo antimicrobials (OPP) in the Canadian Adult Dyspepsia Empiric Treatment-H. pylori-positive (CADET-Hp) study. AIM: To perform an economic evaluation of this 1-year study. METHODS: Following blind eradication treatment, family practitioners managed patients according to their usual practices. Health resource utilization information was collected prospectively. From the mean costs of the health resources consumed and the treatment outcomes, the incremental cost-effectiveness ratios and incremental net benefits of eradication treatment vs. OPP were determined. RESULTS: Eradication therapy significantly improved dyspepsia symptoms (treatment success: OMC, 50%; OPP, 36%; P = 0.02). The incremental cost-effectiveness ratio of OMC vs. OPP was - 387 Canadian dollars (CAD$) per treatment success (90% CI, - CAD$1707, CAD$607), indicating a lower cost with treatment success. The incremental net benefit analysis showed that H. pylori eradication was cost-effective if the willingness-to-pay value exceeded a nominal figure of CAD$100 from a health service perspective or CAD$607 from the societal perspective. CONCLUSION: In uninvestigated patients presenting with dyspepsia at the primary care level, eradication of H. pylori in those who are H. pylori positive leads to a cost-effective improvement in dyspepsia symptoms compared with a strategy of not eradicating H. pylori in these patients.

Adolescent↗