Daniel P. Chin

Adverse impact of cigarette smoking on dimensions of health-related quality of life in persons with HIV infection.

Because effects of cigarette smoking on health-related quality of life (HRQL) have not been well described, we carried out a cross-sectional assessment of HRQL using the Medical Outcomes Survey Scale adapted for patients with human immunodeficiency virus (MOS-HIV questionnaire) in 585 HIV-infected homosexual/bisexual men, injection drug users, and female partners enrolled in a multicenter, prospective study of the pulmonary complications of HIV infection. Mean scores for the following dimensions of HRQL were calculated: general health perception, quality of life, physical functioning, bodily pain, social functioning, role functioning, energy, cognitive functioning, and depression. A multivariate model was used to determine the impact on HRQL of the following factors: smoking, CD4 loss, acquired immune deficiency syndrome (AIDS) diagnoses, number of symptoms, study site, education, injection drug use, gender, and age. Current smoking was independently associated with lower scores for general health perception, physical functioning, bodily pain, energy, role functioning, and cognitive functioning (all with p < 0.05). We conclude that patients with HIV infection who smoke have poorer HRQL than nonsmokers. These results support the use of smoking cessation strategies for HIV-infected persons who smoke cigarettes.

Frequency and importance of barotrauma in 100 patients with acute lung injury.

OBJECTIVES To determine the occurrence rate of barotrauma in acute lung injury patients, whether barotrauma is an independent risk factor for mortality, and the role of barotrauma in the outcome of those patients who died. DESIGN Prospective, cohort study. SETTING Intensive care units at a university hospital. PATIENTS Consecutive adult patients (n = 100) meeting the usual criteria for a diagnosis of acute lung injury requiring mechanical ventilation. MEASUREMENTS AND MAIN RESULTS Barotrauma occurred in 13 (13%) of 100 patients. Mortality rates were not different in patients with (76%) and without (64%) barotrauma. Using univariate analysis, barotrauma was not associated with increased mortality (odds ratio 1.85; confidence interval 0.42 to 9.20; p = .53). However, when barotrauma was incorporated into a logistic regression model, along with other potential predictors of mortality, barotrauma was associated with increased mortality (odds ratio 6.15; confidence interval 1.11 to 33.9; p = .017). The presence of nonpulmonary organ dysfunction and sepsis was strongly associated with mortality. In the setting of barotrauma, the mortality rate was 100% if associated with two or more nonpulmonary organ dysfunctions compared with a mortality rate of 40% with one or no nonpulmonary organ failure. Barotrauma contributed directly to the cause of death in only one patient. CONCLUSIONS Barotrauma occurred in only 13% of patients with acute lung injury. Barotrauma was an independent marker of mortality when adjusted for other predictors of mortality. However, barotrauma directly contributed to < 2% of all deaths. We hypothesize that barotrauma is an indication of severity of acute lung injury rather than a major cause of increased mortality.

Mycobacterial complications of HIV infection.

Tuberculosis is the most common opportunistic infection worldwide and is caused by the only readily transmissible pathogen among persons with HIV infection. If treatment is initiated promptly and is supervised appropriately, cure, fortunately, is highly likely. Isoniazid preventive therapy substantially reduces the risk of tuberculosis in persons with HIV infection. Of the nontuberculous mycobacteria, Mycobacterium avium complex (MAC) is the most frequent cause of disease; however, disseminated MAC disease usually is not seen until the CD4+ cell count is less than 50 cells/L. Newer agents, such as the macrolides and rifabutin, form the nucleus of treatment regimens and also are effective in preventing the disease.

Impact of Bacterial Pneumonia and Pneumocystis carinii Pneumonia on Human Immunodeficiency Virus Disease Progression

The course of pneumonia caused by pyogenic bacteria and Pneumocystis carinii was examined in a multicity cohort study of HIV infection. The median duration of survival among 150 individuals following initial bacterial pneumonia was 24 months, compared with 37 months among 299 human immunodeficiency virus (HIV)-infected control subjects matched by study site and CD4 lymphocyte count (P<.001). For 152 subjects with P. carinii pneumonia, median survival was 23 months, compared with 30 months for 280 matched control subjects (P = .002). Median durations of survival associated with the two types of pneumonia differed by only 47 days, despite a higher median CD4 lymphocyte count associated with bacterial pneumonia. These results suggest that both P. carinii pneumonia and bacterial pneumonia are associated with a significantly worse subsequent HIV disease course. The similarity of prognosis after one episode of bacterial pneumonia vs. an AIDS-defining opportunistic infection and the proportion of cases occurring in association with a CD4 lymphocyte count of >200 suggest that measures to prevent bacterial pneumonia should be emphasized.

Laboratory Reporting of Tuberculosis Test Results and Patient Treatment Initiation in California

ABSTRACT Prompt laboratory reporting of tuberculosis (TB) test results is necessary for TB control. To understand the extent of and factors contributing to laboratory reporting delays and the impact of reporting delays on initiation of treatment of TB patients, we analyzed data from 300 consecutive culture-positive TB cases reported in four California counties in 1998. Laboratory reporting to the specimen submitter was delayed for 26.9% of smear-positive patients and 46.8% of smear-negative patients. Delays were associated with the type of laboratory that performed the testing and with delayed transport of specimens. Referral laboratories (public health and commercial) had longer median reporting time frames than hospital and health maintenance organization laboratories. Among patients whose treatment was not started until specimens were collected, those with delayed laboratory reporting were more likely to have delayed treatment than patients with no laboratory reporting delays (odds ratio [OR] of 3.9 and 95% confidence interval [CI] of 1.6 to 9.7 for smear-positive patients and OR of 13.1 and CI of 5.3 to 32.2 for smear-negative patients). This relation remained after adjustment in a multivariate model for other factors associated with treatment delays (adjusted OR of 25.64 and CI of 7.81 to 83.33 for smear-negative patients). These findings emphasize the need to reduce times of specimen transfer between institutions and to ensure rapid communication among laboratories, health care providers, and health departments serving TB patients.

Genetic Similarity among Mycobacterium avium Isolates from Blood, Stool, and Sputum of Persons with AIDS

Large-restriction-fragment pattern comparison of Mycobacterium avium from 85 blood, stool, and respiratory specimens from 25 human immunodeficiency virus-infected San Francisco patients revealed 4 strains that infected multiple people (3 groups of 2 patients and 1 group of 3 patients). Most patients harbored a single M. avium strain, but 2 strains were recovered from 8 patients. The significance of recovering 2 strains is not clear, since the second strain was seldom recovered more than once. The strain recovered from blood was recovered from stool of 4 patients and respiratory secretions of 6 patients >4 weeks before detection of bacteremia, indicating that the intestinal and respiratory tracts are entry portals from which M. avium can disseminate. M. avium from 21 cities outside of California served as controls. Thus, a single M. avium strain can cause disseminated infection in multiple patients. This may represent infection from a common environmental source or person-to-person spread.

Use of Recommended Laboratory Testing Methods Among Patients with Tuberculosis in California

ABSTRACT This study assessed the extent to which laboratory methods recommended by the Centers for Disease Control and Prevention were used in tuberculosis testing of patients in California in 1998. While recommended methods were used for most patients, there was room for improvement by hospital and independent non-health maintenance organization laboratories.