Christopher Grace

Usefulness of Blood Culture for Hospitalized Patients Who Are Receiving Antibiotic Therapy

We conducted a retrospective study to determine the yield of blood samples drawn for culture during the initial 72 h of antibiotic therapy given to 139 patients who were admitted to the hospital for community-acquired infections or fever. The yield of these blood cultures was predictable and rarely (in only 1 patient [0.72%]) isolated new pathogens.

African Trypanosomiasis in Two Travelers from the United States

African trypanosomiasis is a rare but well-documented cause of fever in United States travelers returning from areas where it is endemic. We report two recently diagnosed cases that involved tourists who went on safari in Tanzania. Review of these and 29 other published cases indicates that disease in returning United States travelers is nearly always of the East African form, a fulminant illness for which prompt diagnosis is necessary. In the United States, timely and appropriate therapy for this disease has resulted in favorable outcomes for most patients. Chemoprophylaxis for East African trypanosomiasis is not recommended, but travelers visiting areas of endemicity should practice appropriate preventive measures to prevent tsetse fly bites.

Elevated Biomarkers of Inflammation and Coagulation in Patients with HIV Are Associated with Higher Framingham and VACS Risk Index Scores

Background Biomarkers of inflammation and altered coagulation are of increasing interest as predictors of chronic disease and mortality in HIV patients, as well as the use of risk stratification scores such as the Framingham index and the Veterans Aging Cohort Study (VACS) score. Methods Demographic and laboratory data for 252 HIV patients were assessed for their relationship with 5 biomarkers: hsCRP, D-dimer, Cystatin C, IL-6 and TNF-alpha. Analysis of variance was used to model the association between the number of elevated biomarkers patients had and their Framingham 10 year cardiovascular risk and VACS scores. Results 87% of patients were male and 75.7% were virally suppressed (HIV RNA <48 copies/ml). The median and interquartile ranges for each biomarker were: hsCRP 1.65 ug/mL (0.73, 3.89), D-dimer 0.17 ug/mL (0.09, 0.31), Cystatin C 0.87 mg/L (0.78, 1.01), IL-6 2.13 pg/mL (1.3, 3.59), TNF-alpha 4.65 pg/mL (3.5, 5.97). 62.6% of patients had more than one biomarker >75th percentile, while 18.6% had three or more elevated biomarkers. Increased age, cigarette smoking, CD4 counts of <200 cells/mm3, Framingham scores and VACS scores were most strongly associated with elevations in biomarkers. When biomarkers were used to predict the Framingham and VACS scores, those with a higher number of elevated biomarkers had higher mean VACS scores, with a similar but less robust finding for Framingham scores. Conclusions Despite viral suppression and immunological stability, biomarkers of inflammation and coagulation remain elevated in a significant number of patients with HIV and are associated with higher scores on risk stratification indices.

Early Clinical Markers and Cd4 Percentage in Subjects with Human Immunodeficiency Virus Infection

In a clinical trial involving asymptomatic, HIV-seropositive subjects treated with either the HIV-1 immunogen (an inactivated, gp120-depleted HIV-1 virus in incomplete Freunds adjuvant) or an adjuvant control, we examined the relationship between changes in the percentage of CD4 cells over time and early clinical markers of HIV disease progression. Subjects who had an early clinical event were more likely to have a greater decline in the percentage of CD4 cells than those subjects who did not have a clinical event (p = 0.054). The greatest decline in CD4 percentage occurred within 10 weeks prior to a clinical event (mean 11% decrease from baseline). Subjects from the quartile with the greatest decline in CD4 percentage had a fivefold greater risk of having a clinical event than subjects from the quartile with the second largest decline (p = 0.045). These results demonstrate a relationship between changes in the percentage of CD4 cells and early clinical events. Further validation of this association may be useful in clinical monitoring and in evaluating therapies to treat HIV infection.

The Vermont Model for Rural HIV Care Delivery: Eleven Years of Outcome Data Comparing Urban and Rural Clinics.

CONTEXT Provision of human immunodeficiency virus (HIV) care in rural areas has encountered unique barriers. PURPOSE To compare medical outcomes of care provided at 3 HIV specialty clinics in rural Vermont with that provided at an urban HIV specialty clinic. METHODS This was a retrospective cohort study. FINDINGS Over an 11-year period 363 new patients received care, including 223 in the urban clinic and 140 in the rural clinics. Patients in the 2 cohorts were demographically similar and had similar initial CD4 counts and viral loads. There was no difference between the urban and rural clinic patients receiving Pneumocystis carinii prophylaxis (83.5% vs 86%, P= .38) or antiretroviral therapy (96.8% vs 97.5%, P= .79). Both rural and urban cohorts had similar decreases in median viral load from 1996 to 2006 (3,876 copies/mL to <50 copies/mL vs 8,331 copies/mL to <50 copies/mL) and change in percent of patients suppressed to <400 copies/mL (21.4%-69.3% vs 16%-71.4%, P= .11). Rural and urban cohorts had similar increases in median CD4 counts (275/mm(3)-350/mm(3) vs 182 cells/mm(3)-379/mm(3)). A repeated measures regression analysis showed that neither fall in viral load (P= .91) nor rise in CD4 count (P= .64) were associated with urban versus rural site of care. Survival times, using a Cox proportional hazards model, were similar for urban and rural patients (hazard ratio for urban = 0.80 [95% CI, 0.39-1.61; P= .53]). CONCLUSIONS This urban outreach model provides similar quality of care to persons receiving care in rural areas of Vermont as compared to those receiving care in the urban center.

Injection Drug Use (IDU) Related Human Immunodeficiency Virus Infection in Rural Vermont: A Comparison with Non-IDU Related Infections

SUMMARY The epidemic of HIV infection is spreading into rural areas of the United States. Injection drug use (IDU) is contributing to this spread in a manner similar to that of larger urban areas. The purpose of this paper is to assess the extent that IDU contributes to the HIV epidemic in Vermont and to compare this group of patients to others infected by HIV by non-IDU means. Twenty-three percent of 119 HIV-positive patients attending rural clinics in Vermont identified IDU as the most likely route of their HIV infection. Another 25% were infected by heterosexual contact with someone at risk for HIV. The majority of patients reported that they became infected with HIV outside of Vermont. Over 40% of IDU patients were first diagnosed with HIV after moving to Vermont. Proportionately more women and minorities were HIV infected by IDU when compared to men and white non-Hispanic patients. The great majority of IDUs were unemployed and depended on welfare or disability for financial support. All IDUs had either Medicaid or Medicare. Most IDU patients had advanced HIV infection upon presentation, with 56% having AIDS and 74% having CD4 counts less than 500 cells/mm. IDU is having a large impact on the HIV epidemic in Vermont both medically and economically and is contributing to the growing epidemic in rural America.