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Patients undergoing endoscopy are at risk of infection from the use of contaminated equipment. Dangers arise from the transmission of organisms from one patient to another and from the introduction of opportunist organisms which colonize endoscopic equipment on storage and can lead to sepsis and death in those who are immunocompromised and at ERCP. Staff are in danger from needle-stick injury and sensitivity to aldehyde disinfectants. These risks can be eliminated by careful attention to disinfection techniques. The most important part of endoscope disinfection is thorough mechanical cleaning first, followed by 5-10 min total immersion of the instrument and all channels in 2% glutaraldehyde (or the equivalent). At the end of the endoscopy list, following the disinfection protocol, all equipment should be dried internally and externally prior to storage. Staff must be fully aware of the risks of infection in endoscopy, be protected from hepatitis B by vaccination, and be fully trained in disinfection techniques. Glutaraldehyde should be used only in closed systems or in well-ventilated areas with the operator protected from direct contact from splashing and fumes. Institutions should designate an individual to be responsible for preparing, monitoring and overseeing disinfection procedures within the endoscopy room and for ensuring that regular microbiological testing of equipment (including automatic disinfecting machines) is undertaken.
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PMID:Disinfection of endoscopic equipment. 190 62

Among 149 kidneys transplanted in 141 children and teenagers aged 4 1/2 to 20 years, from November 1972 through December 1979, 70 (47%) were still functioning after ten years (67/145 cadaver donor grafts and 3/4 living related donor grafts). Medical and social status at the last follow-up visit (10 to 16 1/2 years after transplantation; m = 12 years) was analyzed. Patients were divided into five groups on the basis of glomerular filtration rate (GFR; ml/min/1.73 m2) and blood pressure (BP): 1) GFR greater than 80 ml and normal BP: 23 patients (33%); 2) GFR in the 60-80 ml range and/or high BP: 24 patients (34%/3) GFR in the 40-60 range: 6 patients; 4) GFR in the 15-40 range: 7 patients; and 5) hemodialysis restarted 10 1/2 to 13 years after transplantation. Mean adult stature was 155.7 +/- 10.4 cm in males and 149.8 +/- 10 cm in females. Osteoporosis was found in 88% of patients who underwent bone density quantitation. Twenty-four per cent of patients had aseptic osteonecrosis with variable degrees of impairment as a result. Chronic HBsAg carrier status was found in 37% of patients and was accompanied with persistent cytolysis in half the cases. Only one malignancy was seen (carcinoma of the urinary bladder in a child under cyclophosphamide). Six deaths were recorded between 10 and 13 years after transplantation; causes included septicemia (2 cases), cancer (1 case), hepatitis B (1 case), cerebral cystinosis (1 case), and unexplained sudden death (1 case).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Clinical evaluation of 70 pediatric renal transplants after 10 to 17 years]. 192 8

The banking of femoral heads from patients who undergo total hip arthroplasty provides a valuable resource for orthopedic surgery. Quality assurance of the banked bone used in clinical procedures requires documented policies for screening, procuring, storing and distributing. Potential donors are screened at the time of donation for malignant disease, possible communicable disease, sepsis and high-risk life-styles. After negative culture results are confirmed and appropriate documentation has been completed, the bone is frozen at -70 degrees C. A quarantine period of 90 days follows. The donor is followed up 90 days or more postoperatively. At that time written consent is obtained for donation of the recovered tissue to the bone bank and for serology testing for human immunodeficiency virus (HIV-1) antibody, hepatitis B surface antigen (HBsAG), hepatitis B core antibody (HBcAb) and syphilis, and the donor is rescreened for contraindications. This protocol meets or exceeds all existing standards. The combination of obtaining consent and serology testing at 90 days streamlines the logistics of banking bone from surgical donors.
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PMID:A simplified protocol for banking bone from surgical donors requiring a 90-day quarantine and an HIV-1 antibody test. 186 83

To determine trends in a variety of dialysis-associated diseases and practices, the Centers for Disease Control surveyed 1,734 chronic hemodialysis centers in the United States in 1988 in conjunction with the annual facility survey performed by the Health Care Financing Administration. The response rate to a mailed questionnaire was 91%. These 1,586 centers represented 107,804 patients and 28,501 staff members. Over the last 13 years, the incidence of hepatitis B virus (HBV) infection decreased from 3.0 to 0.2% among patients and from 2.6 to 0.1% among staff members. Over the same time, the prevalence of HBsAg-positivity declined from 7.8 to 1.5% among patients and from 0.9 to 0.3% among staff members. Hepatitis B vaccine was given by 90% of the centers. By the end of 1988, 17% of susceptible patients and 53% of susceptible staff members had received all three doses of hepatitis B vaccine. From 1982 to 1988, as a result of receiving vaccine, the prevalence of antibody to HBsAg increased from 12 to 20% among patients and from 18 to 54% among staff. The incidence of non-A, non-B hepatitis in 1988 was reported to be 1.0% among patients and 0.1% among staff members. Fifteen percent of the centers reported pyrogenic reactions in the absence of septicemia among their patients and 45% reported septicemia. The reported incidence of dialysis dementia among hemodialysis patients was 0.2%, with a case fatality rate of 25%. In 1988, 67% of centers reported that they reused disposable dialyzers; these centers treated 72% of the dialysis patient population. Among centers that reused disposable dialyzers, the average number of reuses ranged from 2 to 50 (mean, 11) and the maximum number of times a disposable dialyzer was reused ranged from 3 to 131 (mean, 28). Chemical germicides used for reprocessing dialyzers included formaldehyde; Renalin, a peracetic acid-hydrogen peroxide-based germicide; and glutaraldehyde-based germicides. Reuse of disposable dialyzers was not associated with any increased risk of acquiring HBV infection among either patients or staff. However, pyrogenic reactions occurring in clusters were more frequently reported in centers that reused conventional dialyzer membranes compared with centers that did not. This increased risk was only associated with centers that reused these dialyzers in a manual reprocessing system, a result consistent with those obtained in 1986 and 1987. Eighteen percent of centers reported treating at least some of their patients by high flux dialysis.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:National surveillance of dialysis-associated diseases in the United States, 1988. 214 Feb 68

This article has provided an overview of the effects of HIV on renal function. Most transmission of the virus occurs by sexual, blood, and perinatal contact. CD-4 positive cells, especially those that are integral components of the immune system, serve as the reservoir for the reproduction of the virus. The resulting effect is destruction of the immune system with eventual multisystem failure and death. Renal complications arise from several factors, notably the compounding effects of chronic dehydration, malnutrition, infection, and use of nephrotic agents. Acute renal complication can be reversible with prompt assessment, and management directed at maintaining hydration, preventing sepsis, and carefully monitoring drugs. A chronic, irreversible renal disease in HIV is due, in large part, to a syndrome known as AIDS nephropathy, characterized by glomerular sclerosis and nephrotic-type symptoms, which ultimately lead to the need for dialysis. Aids nephropathy is seen most often in intravenous drug users, Haitians, and blacks with HIV. End-stage disease complicates the course of HIV and contributes to early mortality. A small, but significant number of renal patients acquires HIV infection as a result of multiple blood transfusions or through organ donation. Concentrated exposure to blood and body fluid during dialysis necessitates implementation of meticulous infection control procedures to protect both staff and patients. Guidelines by the CDC suggest that universal precautions adequate to prevent the spread of hepatitis B will suffice for HIV as well. HIV infection presents special challenges for those involved with renal management. Prevention and management of renal complication are made possible by thorough understanding of the complex network and interaction of the disease process.
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PMID:Renal system complications in HIV infection. 219 22

We conducted a prospective, randomized trial to study the efficacy and tolerance of long-term versus short-term treatment with recombinant interferon alfa-2a in patients with chronic hepatitis B. Ten patients were randomly assigned to a 6-month interferon regimen, and 10 patients were assigned to a 3-week interferon trial. Eleven patients (five assigned to long-term treatment and six to short-term treatment) did not complete interferon therapy: eight had either severe thrombocytopenia or neutropenia; one had pronounced fatigue in relationship to administration of interferon; one had spontaneous bacterial peritonitis and sepsis and died; and one had a massive fatal variceal hemorrhage during interferon therapy. Most of the serious hematologic complications occurred in patients with cirrhosis and hypersplenism. In one patient, seroconversion to hepatitis B virus DNA negativity occurred before the onset of treatment. Four of the five patients able to complete the 6-month interferon regimen and only one of four patients able to complete the 3-week trial had seroconversion to hepatitis B virus DNA negativity. Thus, we conclude that the therapeutic response was better among patients who were able to complete a 6-month interferon trial. In patients with cirrhosis and hypersplenism, development of either severe thrombocytopenia or leukopenia associated with interferon therapy precluded completion of treatment.
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PMID:Long-term versus short-term treatment with recombinant interferon alfa-2a in patients with chronic hepatitis B: a prospective, randomized treatment trial. 221 80

We have studied the outcome of 140 general surgical procedures in 112 patients known or suspected to be infected with human immunodeficiency virus (HIV) or hepatitis B virus. Forty patients had antibodies to HIV. A wide range of surgical procedures was performed, with an overall complication rate of 5.7%. Wound infection, wound haematoma and one unexplained pyrexia were the only complications seen. Some anorectal wounds in patients with HIV antibodies were noted to heal extremely slowly, but the aggressive anorectal sepsis reported by others was not seen. The postoperative course after general surgical procedures was unremarkable in patients with HIV antibodies, and in those suspected of HIV infection, but because anorectal wounds were found to heal slowly, we recommend that anorectal surgery be conservative in patients with HIV antibodies.
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PMID:Surgical procedures in patients at risk of human immunodeficiency virus infection. 185 69

Between January 1985 and December 1987, seventy-five children of intravenous heroin-addicted parents (one or both) were studied. Their ages ranged from 4 days to 14 years. All patients had suffered from several pediatric diseases. Three major types of problems were found among the children studied: infectious diseases, nutritional diseases, and parental neglect and/or disinterest. The most common diagnoses at discharge were gastroenteritis (24%), pneumonia (21%), malnutrition (17%), upper airway infectious diseases (13%), septicemia (12%), child abuse (4%), acquired immunodeficiency syndrome (3%), and other infectious diseases (24%). Their parents reported hepatitis B virus infection, acquired immunodeficiency syndrome (AIDS), and alcoholism. The unemployment rate among the fathers was 37%. Sixteen percent of mothers were prostitutes. There was an imprisonment record of 19% for mothers and fathers combined. A multidisciplinary approach for this group of children would make prevention possible and care less expensive.
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PMID:Social and medical problems in children of heroin-addicted parents. A study of 75 patients. 239 28

This review describes the transmission, clinical picture and immunological abnormalities of HIV infection in children in general, and the special problems of AIDS in African children. The review begins with a thorough introduction to the epidemiology of AIDS. Transmission to children generally involves vertical transmission by placental transfer or transmission of HIV via transfusion of blood and blood products, or by contaminated needles. Casual transfer is unknown, and only a few cases of transmission via breast milk are known. The clinical picture of HIV infection in infants and children differs from that in adults in 3 important aspects: earlier onset, different clinical presentation and existence of AIDS embryopathy. The average onset was 5 months of age. The most common symptoms in young children are chronic interstitial pneumonitis without demonstrable etiology, hepatomegaly, failure to thrive, adenopathy, diarrhea, oral or perineal thrush, eczema and thrombocytopenia. The common opportunistic infections are pneumocystis carinii pneumonia, cytomegalovirus, Epstein-Barr virus, Cryptosporidium diarrhea, pyogenic infections of the middle ear and gram-negative septicemia. Several infections seen in adult AIDS cases are rare in children: mycobacterium avium-intracellulare, toxoplasma gondii, hepatitis B, as well as Kaposi's sarcoma, malignant lymphoma and cardiac abnormalities. The AIDS embryopathy or HIV dysmorphic syndrome is characterized by immunological abnormalities, growth failure, and craniofacial dysmorphism, particularly microcephaly, prominent box-like forehead, hypertelorism, flattened nasal bridge, obliquity of the eyes, blue sclerae and patulous lips. AIDS in African children is extremely difficult to diagnose because of similarities between the presenting symptoms and those commonly seen in sick children there, many of whom are also immune compromised. Where serotesting is available, the picture is complicated by cross reaction between the test agents and some factor found in sera from malaria patients. Seropositivity in some areas is high, increased by the prevalence of transfusion and injection treatments. Diagnosis is made more difficult by lack of laboratory facilities and difficulties in follow-up for pediatric patients. The CDC definitions of AIDS and ARC, and the WHO/CDC definitions of AIDS are appended.
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PMID:Human immunodeficiency virus infection in childhood. 245 15

The Centers for Disease Control surveyed 1,630 chronic hemodialysis centers in the United States in 1987 in conjunction with the annual facility survey done by the Health Care Financing Administration. Information was obtained on the following diseases and practices: 1) hepatitis B virus (HBV) infection in patients and staff members; 2) infection control procedures for hepatitis B surface antigen (HBsAg)-positive patients; 3) frequency of HBsAg serologic screening; 4) use of hepatitis B vaccine; 5) non-A, non-B hepatitis in patients and staff members; 6) pyrogenic reactions and septicemia; 7) dialysis dementia; 8) new dialyzer syndrome; 9) high flux dialysis; 10) reuse of dialyzers, dialyzer caps, bloodlines, transducer filters; 11) cleaning and disinfection procedures; and 12) human immunodeficiency virus (HIV) infection. The response rate to a mailed questionnaire was 91%. These 1,486 centers represented 97,225 patients and 27,123 staff members. During the last 12 years, the incidence of HBV infection decreased from 3.0% to 0.2% among patients and from 2.6% to 0.1% among staff members. Over the same time, the prevalence of HBsAg-positivity declined from 7.8% to 1.7% among patients and from 0.9% to 0.4% among staff members. Hepatitis B vaccine was given by 88% of the centers. By the end of 1987, 14% of susceptible patients and 49% of susceptible staff members had received all three doses of hepatitis B vaccine. From 1982 to 1987, as a result of receiving vaccine, the prevalence of antibody to HBsAg (anti-HBs) increased from 12% to 18% among patients and from 18% to 50% among staff. The incidence of non-A, non-B hepatitis in 1987 was reported to be 1.2% among patients and 0.2% among staff members. Fourteen percent of the centers reported pyrogenic reactions among their patients, and 46% reported septicemia in the absence of pyrogenic reactions. Pyrogenic reactions were significantly more likely to be reported by centers that practiced high flux dialysis. The reported incidence of dialysis dementia among hemodialysis patients was 0.2%, with a case fatality rate of 29%. Among patients developing dialysis dementia, the case fatality rate was higher in those centers that used deionization (DI) without reverse osmosis (RO) (47%) compared with centers that used RO (28%) (not significant, p greater than 0.05). In 1987, 64% of centers reported that they reused disposable dialyzers. These centers treated 70% of the dialysis patient population.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:National surveillance of dialysis-associated diseases in the United States, 1987. 255 96


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