Faculty Bibliography

Seven patients with AIDS-related cognitive and emotional deficits had neuropsychologic testing and then were treated with methylphenidate or dextroamphetamine in individualized doses. Three patients showed marked functional improvement and 5 of the 7 became more spontaneous, reactive, and animated. Additional neuropsychologic testing showed statistically significant improvement in a subset of tests; however, scores did not return to baseline in tests done after the treatment was discontinued for 1-3 days

Five cases of large tuberculous abscesses in patients with AIDS were observed over a 2-year period at the New York Veterans Affairs Medical Center. These cases represent 11.6% of the 43 cases of tuberculosis diagnosed in patients with AIDS during that period. The abscesses were located in the liver, abdominal wall, psoas muscle, mediastinum, and peripancreatic area. All patients presented with localized pain or swelling, and four of five patients had fever. The diagnosis was made on the basis of detection of abscesses on computed tomography (CT) and the results of culture of abscess material obtained by CT-guided aspiration. CT-guided therapeutic drainage was performed in two cases. Despite administration of therapy, two of five patients died of tuberculous infection. Formation of tuberculous abscesses appears to be a common complication of tuberculosis in patients with AIDS. This diagnosis should be considered for patients with AIDS who have fever and localized pain or swelling

BACKGROUND. Zidovudine is recommended for asymptomatic and early symptomatic human immunodeficiency virus (HIV) infection. The best time to initiate zidovudine treatment remains uncertain, however, and whether early treatment improves survival has not been established. METHODS. We conducted a multicenter, randomized, double-blind trial that compared early zidovudine therapy (beginning at 1500 mg per day) with late therapy in HIV-infected patients who were symptomatic and had CD4+ counts between 0.2 x 10(9) and 0.5 x 10(9) cells per liter (200 to 500 per cubic millimeter) at entry. Those assigned to late therapy initially received placebo and began zidovudine when their CD4+ counts fell below 0.2 x 10(9) per liter (200 per cubic millimeter) or when the acquired immunodeficiency syndrome (AIDS) developed. RESULTS. During a mean follow-up period of more than two years, there were 23 deaths in the early-therapy group (n = 170) and 20 deaths in the late-therapy group (n = 168) (P = 0.48; relative risk [late vs. early], 0.81; 95 percent confidence interval, 0.44 to 1.59). In the early-therapy group, 28 patients progressed to AIDS, as compared with 48 in the late-therapy group (P = 0.02; relative risk, 1.76; 95 percent confidence interval, 1.1 to 2.8). Early therapy increased the time until CD4+ counts fell below 0.2 x 10(9) per liter (200 per cubic millimeter), and it produced more conversions from positive to negative for serum p24 antigen. Early therapy was associated with more anemia, leukopenia, nausea, vomiting, and diarrhea, whereas late therapy was associated with more skin rash. CONCLUSIONS. In symptomatic patients with HIV infection, early treatment with zidovudine delays progression to AIDS, but in this controlled study it did not improve survival, and it was associated with more side effects

To determine the excess mortality attributable to hospital-acquired bloodstream infections, we applied the acute physiology and chronic health evaluation (APACHE) II classification to 34 critically ill patients with this complication. The study included primary bloodstream infections, defined by a positive blood culture at least three days after hospitalization, in the absence of any other apparent source of infection. The most frequent blood isolates included Staphylococcus aureus (39 percent), Gram-negative rods (24 percent), and Candida albicans (15 percent); the spectrum of blood isolates suggested that most infections were related to intravascular catheters. In a control group of intensive care unit patients (n = 384), the death rate predicted by APACHE II was similar to the observed death rate (35.3 vs 37.8 percent). In a subgroup of control patients (n = 34), chosen for APACHE II scores that matched the patients with bloodstream infections, predicted and observed death rates were also similar (53.1 vs 52.9 percent). For patients with bloodstream infections, however, observed mortality (82.4 percent) significantly exceeded the predicted value (54.1 percent, p = 0.025). We conclude that critically ill patients who develop nosocomial bloodstream infections are at greater risk of death than patients with comparable severity of illness without this complication. The difference between the observed and predicted death rates, 28 percent, represents the excess mortality associated with bloodstream infection in critically ill patients

Over 91,000 cases of AIDS have been reported in United States, and it has been estimated that more than 1 million individuals are currently infected by the human immunodeficiency virus (HIV). The disease is growing most rapidly among intravenous drug abusers and minority patients. This accentuates some medical and ethical problems. Chief among these are the availability of competent care for patients and the willingness of physicians to treat these patients, issues related to HIV testing and counseling, patients' rights regarding the extent of treatment that should be given and access to and participation in clinical trials