Subsequent Illness Research Articles

Laboratory investigation of the first suspected human cases of infection with avian influenza A(H5N1) virus in Bulgaria

Reports of human cases of infection with avian influenza A(H5N1) virus have received increased public attention because of the potential for the emergence of a pandemic strain. In the end of 2005 and the beginning of 2006, avian influenza A(H5N1) virus caused outbreaks among domestic poultry and was isolated from wild swans in many European countries, including Bulgaria. Between January and March 2006, samples were collected from 26 patients who had been in close contact with ill or dead birds and developed a subsequent respiratory illness. The testing took place at the National Laboratory of Influenza in Sofia. Specific A(H5N1) assays were applied for screening (Sacace RT-PCR and real-time kit). Avian flu A(H5N1) virus was not detected in any of the patients tested. In three patients, human subtype A(H1N1) influenza virus, identifiable by RT-PCR was isolated and further characterized by hemagglutination inhibition test (HIT). The reliability of the molecular assays used in this investigation was demonstrated in an International Quality Control for Human and Avian A(H5N1) Influenza performed later in 2006 by INSTAND (Society for Promotion of Quality Assurance in the Medical Laboratories), Germany.

Seasonal inactivated influenza virus vaccines

Inactivated influenza virus vaccines are the primary modality used for prevention of influenza. A system of annual identification of new strains causing illnesses, selections for vaccines, chick embryo growth, inactivation, processing, packaging, distribution and usage has been in place for decades. Current vaccines contain 15 μg of the HA of an A/H1N1, A/H3N2 and B strain and are given parenterally to induce serum anti-HA antibody for prevention of subsequent infection and illness from natural influenza. Reactogenicity is low and protection among healthy older children and adults is good; protection levels are generally lower in young children and the elderly. Needs include ensuring antigenic matches of vaccine and epidemic viruses each season, enhancing immunization rates, and providing new and improved vaccines and immunization approaches for the varied populations and circumstances globally.

Deciphering the Cost Impact of Managed Care in Medicaid

Deciphering the Cost Impact of Managed Care in Medicaid

A longitudinal study of the relationship between psychological distress and recurrence of upper respiratory tract infections in chronic fatigue syndrome

Previous research has found that chronic fatigue syndrome (CFS) patients report increased susceptibility to upper respiratory tract illnesses (URTIs) when compared with healthy volunteers. This study aimed to replicate and extend this research by investigating the role of psychological distress (stress and negative mood) in the recurrence of URTIs in CFS patients as well as its role in the recurrence of CFS symptoms. A 15-week diary study. Measures of psychological stress, negative mood, recurrence of URTIs and symptoms were recorded each week for a 15-week period. CFS patients (N=21), who had been assessed and diagnosed according to the Oxford criteria, were recruited from the Cardiff Chronic Fatigue Clinic and compared with a matched group of healthy controls (N=18). Frequency of occurrence of infectious illness and the relationship between psychological stress/negative mood and occurrence of illness were assessed. CFS patients reported more URTIs than the controls. Stress scores (and negative mood) were significantly higher in the week prior to the occurrence of URTIs than in weeks when no subsequent illness occurred. High levels of psychological stress also preceded the severity of reported symptoms of fatigue in the CFS group. CFS patients reported more frequent URTIs than healthy controls and these recurrences were preceded by high levels of psychological stress. High levels of stress were also associated with greater subsequent fatigue. Possible explanations of these results are discussed.

The Risk for Schizophrenia From Childhood and Adult Infections

The Risk for Schizophrenia From Childhood and Adult Infections

Challenges faced by palliative care physicians when caring for doctors with advanced cancer

Background : It is possible that patients with advanced cancer, who are from the medical profession, have different or additional care needs than other patients. Previous training, professional experiences and access to information and services may influence their needs and subsequent illness behaviour. Caring for `one of our own' may also evoke particular feelings and emotions from health professionals involved in their care and pose unique challenges in the delivery of equitable patient-centred care. Aim : To explore the experiences of palliative care physicians when caring for members of the medical profession with advanced incurable cancer. Participants and methods : Semi-structured interviews exploring the experiences of senior palliative care physicians were recorded and transcribed verbatim. Transcripts were analysed using interpretative phenomenological analysis (IPA) for emergent themes. Data were collected from ten senior palliative care physicians with a combined total of 107 years of palliative care career experience, caring for a reported combined estimate of 120 doctor—patients. Results : On the basis of their reflections, palliative care physicians reported that doctor—patients appear to find it difficult to assume a patient role, especially at a time they are likely to be truly vulnerable. This patient group will routinely attempt to maintain control of their care and environment using various strategies. These include self-referrals, accessing their own tests, directing the consultation and putting barriers up to psychosocial aspects of palliative care. Doctor—patients' general practitioners are at risk of exclusion from the management of care, and referral to palliative care services appears to occur later in the illness journey of doctor—patients compared to lay patients. Participants recalled how caring for colleagues evokes powerful emotional responses, such as a strong desire to provide the best care possible as well as feelings of anxiety. They frequently find themselves under pressure to disclose confidential information from medical colleagues not involved in the doctor—patients' care. Doctor—patients frequently receive what other healthcare professionals perceive as preferential treatment, which may unintentionally result in suboptimal care. Conclusion : The core needs of doctors with advanced cancer could be assumed to be the same as other patients. However, the juxtaposition of role from professional to patient appears to evoke unique care needs from the patient, and behaviour responses from the professional. Forewarning and awareness of these issues may help prevent potential problems in this patient group's cancer journey as well as the experience of the professionals involved in their management. Palliative Medicine 2008; 22 : 71—76

The Effect of Transportation Noise on Health and Cognitive Development:A Review of Recent Evidence

Noise from transport is an increasingly prominent feature of the urban environment. Whilst the auditory effects of noise on humans are established, non-auditory effects - the effects of noise exposure on human health, well-being and cognitive development - are less well established. This narrative review evaluates recent studies of aircraft and road traffic noise that have advanced or synthesized knowledge about several aspects of adult and child health and cognition. Studies have demonstrated a moderate effect of transport noise on hypertension, cardiovascular disease and catecholamine secretion: there is also evidence for an effect on psychological symptoms but not for the onset of more serious clinically defined psychiatric disorder. One way noise may affect health is through annoyance: noise causes annoyance responses in both children and adults and annoyance may cause stress-responses and subsequent illness. Another possible mechanism is sleep disturbance: transport noise has been found to disturb sleep in laboratory and field studies, although there is evidence for adaptation to noise exposure. For children effects of aircraft and road traffic noise have been observed for impaired reading comprehension and memory skills: there is equivocal evidence for an association with blood pressure. To date most health effects have been very little researched and studies have yet to examine in detail how noise exposure interacts with other environmental stressors. In conclusion, noise is a main cause of environmental annoyance and it negatively affects the quality of life of a large proportion of the population. In addition, health and cognitive effects, although modest, may be of importance given the number of people increasingly exposed to environmental noise and the chronic nature of exposure.

Infections in the CNS During Childhood and the Risk of Subsequent Psychotic Illness: A Cohort Study of More Than One Million Swedish Subjects

Infections during early life have been suggested to play a role in the etiology of schizophrenia. Most studies have focused on fetal life; few have explored risk associated with infection during childhood. The results of these have been inconsistent. The present study aims to investigate whether there is an increased risk of schizophrenia and other nonaffective psychoses associated with viral or bacterial CNS infections during childhood and, if so, which specific agents are involved. A national cohort consisting of 1.2 million children born between 1973 and 1985 was followed up by using Swedish national registers to retrieve data on hospital admissions for CNS infections at 0-12 years of age (bacterial: N=2,435, viral: N=6,550) as well as admissions for nonaffective psychotic illnesses from the 14th birthday (N=2,269). There was a slightly increased risk of nonaffective psychotic illness associated with viral CNS infections, as well as schizophrenia. There was no evidence of increased risk in relation to bacterial infections. When divided into specific agents, exposures to mumps virus or cytomegalovirus were associated with subsequent psychoses. Serious viral CNS infections during childhood appear to be associated with the later development of schizophrenia and nonaffective psychoses. The association with specific viruses suggests that the risk is related to infectious agents with a propensity to invade the brain parenchyma.

Isabelle of France: Capetian Sanctity and Franciscan Identity in the Thirteenth Century (review)

Reviewed by M. C. Gaposchkin Dartmouth College Isabelle of France: Capetian Sanctity and Franciscan Identity in the Thirteenth Century. By Sean L. Field. (Notre Dame, Indiana: University of Notre Dame Press. 2006. Pp. xii, 288. $35.00 paperback.) Isabelle of France (d. 1270), daughter of Louis VIII and Blanche of Castille, sister of Louis IX, devoted virgin of Christ, founder of the Franciscan female convent of Longchamp, pious, ascetic, and princess, was never formally canonized. This, despite the fact that she fit the ideal of pious royal women in the thirteenth century so often sainted (in a pattern of late medieval sanctification now clarified by Gábor Klaniczay), and despite an early and co-ordinated effort, including the writing of an important vita and the backing of her brother, the indomitable Charles of Anjou. Successful canonizations might founder on a myriad of institutional, political, or devotional rocks, but in this case must largely be attributed to Louis IX's own canonization in 1297, overshadowing his sister's fame and filling whatever appetite existed for a Capetian royal saint. In recent years, Sean L. Field has recovered Isabelle. First, in his edited edition of Agnes of Harcourt's Life of Isabelle of France, written in the 1280's (Sean L. Field, The Writings of Agnes of Harcourt: The Life of Isabelle of France and the Letter on Louis IX and Longchamp [Notre Dame, Indiana, 2003]), and now in his new biography of Isabelle herself (under review here), Field has explored Isabelle's career. As he indicates in his introduction (pp. 5-8), the life of Isabelle of France relates to three central themes in late medieval history—the power of women, sanctity and sanctification, and the development of female Franciscan spirituality and institutions. It is also a fascinating exploration of an extraordinary woman—from her rejection [End Page 914] of the putative heir to the imperial throne (Conrad, son of Frederick II), to her commitment to lifelong virginity, to her deft negotiations with popes and kings, to her ability to quietly translate her moral authority as a consecrated virgin into political influence, to the veneration shown her after her death. Field argues that in the 1250's Isabelle was seen as a budding saint whose fame and renown was spreading beyond the court, who was recognized as such by contemporaries like Pope Alexander IV and Thomas of Cantimpré, and who was able to translate this reputation into effective power. The dual attributes of virginity and royalty were the defining features of Isabelle's identity for contemporaries. The book is structured chronologically. The first chapter examines Isabelle's childhood and negotiations for a political marriage. Her refusal to marry, and a subsequent illness, led to a vow of virginity which shaped her vocation and her life. Chapter two chronicles her cultivation of an independent (virginal) identity within the politics of the court, and her attraction, in the 1240's and '50's, to the Franciscan Order. Chapters three and four discuss her foundation of Longchamp, and, in Field's words, the "process by which she parlayed her royal status and religious renown into a role as co-author of a new form of life for Franciscan women" (p. 61). It is notable that Isabelle chose to found a Franciscan convent, rather than the hospital for the poor that she first considered (and in which she would have emulated existing models of female royal sanctity found in Agnes of Prague and Elizabeth of Hungary). Field traces the driving role Isabelle played in the composition of a rule in 1259, and then a revised rule of 1263 in which she won the right to call her nuns Sorores Minores. Field argues that although politicized considerations downplayed explicit record of Isabelle's contributions, her hand and her influence are evident, as with, for example, a move to strengthen the abbess's institutional power. The rule was subsequently adopted by Franciscan convents in France, England...

Vakuumversiegelung – Grundlagen, Indikationen, Kontraindikationen und Kostenbilanz

Vacuum therapy is an efficient alternative to conservative wound care and creates new possibilities for the treatment of a variety of chronic and acute wounds. Already more than two thousand years ago vacuum treatment was applied in traditional Chinese medicine and also today vacuum therapy is used more and more frequently in daily clinical practice. The positive effects of the therapy are based on the stimulation of blood flow, formation of granulation tissue, angiogenesis, as well as cell proliferation, accelerated secondary wound closure and the removal of bacteria from the wound. As can be demonstrated based on a clinical picture of the open abdomen, vacuum therapy based on KCI's (Kinetic Concepts Inc) VA.C. system (Vacuum Assisted Closure) provides a possibility for not only accelerating the healing process, but also significantly lowering mortality. Since vacuum therapy in the form of the V.A.C. system represents a relatively expensive intervention, a comparison with conventional healing methods is demonstrated. Clinical studies with high evidence level show that both economic and clinical advantages of the vacuum therapy speak for its application. Savings with respect to the faster healing rates, the reduced dressing changes, as well as hospital stay and the care requirements, and the reduction of subsequent illnesses, compensate for the higher initial costs. Although many reports exist on treatment successes with the application of V.A.C. therapy, there are several cases for which vacuum therapy is contraindicated. In order to make sure that V.A.C. therapy is effective, a range of precautions and contraindications are described. The European Wound management Association (EWMA) just wrote a position paper on V.A.C. therapy. This is available at www.ewma.org.

Exposure to Pulmonary Tuberculosis in a Neonatal Intensive Care Unit: Unique Aspects of Contact Investigation and Management of Hospitalized Neonates

We describe the investigation of a tuberculosis (TB) exposure in which a neonatal intensive care unit (NICU) respiratory therapist was the index patient, as well as the rationale by which exposed infants were managed and possible explanations for the lack of transmission to these patients. Description of an exposure investigation. Academic, level IV NICU of a tertiary care children's hospital. Contacts of a respiratory therapist with pulmonary TB disease, including household members, healthcare coworkers, and infant patients. In addition to 5 household contacts, 248 healthcare coworkers and 180 infant patients were identified as possibly exposed during the 24 days that the index patient worked between December 3, 2004, and January 30, 2005. Tuberculin skin tests (TSTs) were performed for 233 of the 235 contacts with the greatest degree of exposure (household and coworker contacts) who had a previously documented negative TST result or whose TST status was unknown prior to the investigation. No cases of latent tuberculosis infection or TB disease were identified. Because of characteristics of the index case, the exposure duration and setting, the infants' small lung volumes, and lack of evidence of transmission to higher-risk contacts, infants were not clinically evaluated or empirically treated for TB disease. Surveillance for subsequent illness was carried out by primary healthcare providers and parents. No TB disease or unexplained illness in these infants was reported in the 20 months following the exposure. After limited hospital exposure to a healthcare worker with pulmonary TB disease who is not highly contagious, neonates can be safely managed without specific evaluation for TB disease or empirical treatment.

Polymerase chain reaction in the detection of an ‘outbreak’ of asymptomatic viral infections in a community birth cohort in south India

Asymptomatic enteric infections are important where sequelae or protection from subsequent illness is an outcome measure. The use of reverse transcription-polymerase chain reaction (RT-PCR) to identify asymptomatic enteric infections in a birth cohort followed for rotaviral infections in a south Indian urban slum is reported. Of 1191 non-diarrhoeal samples from 371 children collected in May-June 2003, 22 (1.9%) were positive by ELISA. A total of 147 (40.6%) of 362 samples tested by VP6 RT-PCR were positive. In those samples that could be typed, a high diversity of G types including G1, G2, G4, G8, G9 and G10, and a high proportion (34.4%) of mixed infections were detected. Noroviruses were identified in 6/28 (21.4%) samples tested. The identification of infections undetectable by conventional techniques indicates the importance of the use of sensitive diagnostic techniques in research studies. Asymptomatically infected children may also act as a source of infection for other susceptible hosts.

Illness, Disease and Sin: The Connection Between Genetics and Spirituality

The New Testament, while rejecting any superficial connection between illness and sin, does not reject a possible connection between illness and a person's relationship with God. An example can be seen in the story of the young blind man who was healed (St. John 9:3). His blindness does not result from any fault he or his parents had committed but apparently from God's wish to reveal his own healing power. The inner blindness of the Pharisees is a different type of blindness far more difficult to heal. The blind young man was actually healed, not only in body but also in soul. Such miraculous healings are rare nowadays. However, if one takes a closer look at modern genetics and psycho-neuro-immunological findings, one may come to a better understanding of how miracle healings are linked to man's inner life and therefore also to his religiousness. Many diseases have genetic backgrounds. Defective genes, however, do not necessarily lead to subsequent illness. Genes have to be switched on or off. Only activated genes trigger pathological change. The human brain and all of man's thinking and feeling are intimately connected with such activations. We may thus conclude that both inner life and religious outlook on life are relevant to the origin and development of diseases.

A control system for automatic electrical stimulation of abdominal muscles to assist respiratory function in tetraplegia

People with tetraplegia have poor respiratory function leading to limited tidal volume ( V T) and reduced cough peak flow (CPF). These problems may cause respiratory failure during the initial admission or subsequent intercurrent illness. Electrical stimulation of the abdominal muscles during expiration can improve respiratory function by increasing V T and CPF. We developed a novel control system to automatically trigger muscle stimulation, synchronised with the subject's voluntary respiratory activity. The system was tested in four subjects with a functionally complete lesion at level C4 to C6, aged between 16 and 46 years, 3 months to 5 years post injury, who were breathing spontaneously. The algorithm delivered automatic stimulation patterns, detecting cough and quiet breathing while suppressing stimulation during other activities such as speaking. Marked increases in V T (between 9% and 71% of baseline) and CPF (between 31% and 54% of baseline) were observed, suggesting that the technique may have potential use in both acute and established tetraplegia to increase minute ventilation and to improve cough clearance of secretions.

Reply

Rotavirus gastroenteritis is responsible for substantial childhood morbidity worldwide, and is a leading cause of mortality among infants and young children in resource-limited environments. A new generation of rotavirus vaccines offers the promise of saving lives, reducing suffering, and decreasing healthcare resource utilization for this nearly universal early childhood infection. Two efficacious and well-tolerated rotavirus vaccines have been developed based on very different strategies. We recently reported the results of the large, international, blinded, randomized, placebo-controlled Rotavirus Efficacy and Safety Trial (REST), which studied the safety and efficacy of an oral pentavalent human–bovine reassortant rotavirus vaccine (RotaTeq) in healthy infants given the first of 3 doses between 6 and 12 weeks of age. Because the incidence of natural intussusception peaks in children between 4 and 9 months old, younger infants were enrolled to maximize the ability to detect any increased risk of vaccine-related intussusception. The rotavirus serotypes included in the vaccine were selected because they cause the large majority of rotavirus infections in both the developing and developed world. The rationale for including multiple serotypes in the vaccine derives from natural history studies showing that primary rotavirus infection provides immunity against subsequent illness of any severity from the same serotype and protection against severe disease from any serotype (N Engl J Med 1996;335:1022–1028). Although partial protection can be achieved with 2 doses of the pentavalent vaccine, 3 doses are required for optimally broad immune responses (Pediatr Infect Dis J 2006;25:577–583). Bovine-rotavirus reassortants replicate less efficiently than the simian-rotavirus reassortants (J Infect Dis 2001;183:1108–1111) used in the previously licensed and subsequently withdrawn rhesus rotavirus vaccine—tetravalent (RRV-TV; RotaShield) associated with an increased risk of intussusception during the 2 weeks following vaccination. REST did not demonstrate a higher rate of intussusception in vaccine compared to placebo recipients. Furthermore, unlike RRV-TV (Pediatrics 2004;113:e353–359), the incidence of fever and gastrointestinal complications were generally comparable among recipients of the pentavalent rotavirus vaccine and placebo. In light of its rarity, formal post-licensure surveillance for intussusception is continuing. Further analysis of the REST database suggests that the pentavalent rotavirus vaccine will be effective in premature and breastfed infants. Subgroup analyses of Navajo and Jamaican subjects indicate that the pentavalent vaccine can be effective in resource-restrained settings. Because conditions affecting infant health differ around the world, confirmatory clinical trials are being initiated in developing regions of Africa and Asia. Pentavalent rotavirus vaccine can be administered concurrently with the parenteral pediatric vaccines licensed in the United States; concomitant use with oral poliovirus vaccine is currently under study. Given the inclusion criteria established for REST, available safety and efficacy data presently can only support a recommendation for administering the first dose of the pentavalent rotavirus vaccine at 2–3 months of age and completing the full series by age 6–8 months. However, an unintended consequence of age restrictions may be preventable morbidity from rotavirus gastroenteritis among unvaccinated older children. The potential impact of a safe and effective rotavirus vaccine program on global infant health cannot be overstated. We agree with Drs Kamal-Uddin and Croft that “the wheel has turned” for rotavirus vaccines, and look forward to a future when rotavirus no longer poses a major threat to the well-being of children anywhere in the world. The authors may own stock or stock options in Merck & Co., which markets RotaTeq. Rotavirus vaccines: The wheel has turnedGastroenterologyVol. 131Issue 4PreviewRuiz-Palacios GM, Perez-Scchael I, Velazquez FR, Abate H, Breuer T, Clemens SC, Cheuvart B, Espinoza F, Gillard P, Innis BL, Cervantes Y, Linhares AC, Lopez P, Macias-Parra M, Ortega-Barria E, Richardson V, Rivera-Medina DM, Rivera L, Salinas B, Pavia-Ruz N, Salmeron J, Ruttimann R, Tinoco JC, Rubio P, Nunez E, Guerrero ML, Yarzabal JP, Damaso S, Tornieporth N, Saez-Llorens X, Vergara RF, Vesikari T, Bouckenooghe A, Clemens R, De Vos B, O’Ryan M; the Human Rotavirus Vaccine Study Group. (Instituto Nacional de Ciencas Medicas y Nutricion, Mexico Distrito Federal, Mexico). Full-Text PDF

The Expansion Plan of TeleDoc

The TeleDoc project of Jivan Institute has combined mobile commerce and the ancient concepts of Ayurveda for treatment of rural residents of India for whom health services are still available only in dreams. Using GPRS network and J2ME applications on Nokia 6800 mobile phones, TeleDoc field workers are reaching the remotest villages of India with the promise of possible Ayurvedic treatments for subsequent illnesses. With cash-positive results in the first year of operations, TeleDoc wants to expand in a big-bang way by covering 10,000 villages in 2006. They also want to improve the service quality by using real-time video streaming. But many members of the TeleDoc technical team are skeptical whether the existing GPRS-based solution will serve the purpose or not. There are different priorities in the team (e.g., cost-effectiveness, quality of service, availability, immediacy, cost-of-change, etc.). The IT consultant has many options, but getting the priorities sorted out is the daunting task at hand.

Patterns of Health Care Seeking of Gulf War Registry Members Prior to Deployment

Following the Gulf War (GW), large numbers of individuals reported illness that they attributed to exposures encountered during the GW deployment. In response, the Department of Veterans Affairs and the Department of Defense established programs and registries for the evaluation and documentation of GW-related illness. We obtained registrants' medical records, which contained information on outpatient encounters during the 1-year period before their GW deployment, to determine whether registrants with multisymptom illness (cases) have patterns of predeployment health care seeking that are different from those of well registrants (controls). We found that subjects had significantly more predeployment outpatient visits than controls, but this varied by type of visit. Although the number of certain types of predeployment outpatient visits is significantly associated with subsequent multisymptom illness, these associations will have limited predictive value. These findings increase our understanding of multisymptom illness, especially its chronic nature, and justify doing additional studies.

A 43-Year-Old Colonel with Chills, Diaphoresis, and Headache

The objectives were to illustrate the ease with which one might attribute concomitant or subsequent illness to an exposure such as the anthrax vaccine and to demonstrate an approach that keeps the significance of such exposures in appropriate perspective. A 43-year-old, active duty, Army officer presents with a variety of nonspecific common symptoms and raises concerns about the relationship of his symptoms to receipt of the anthrax vaccine. He is admitted for an evaluation that includes a series of diagnostic tests and consultations. The course of his illness and the corresponding evaluation are reviewed using a series of questions and accompanying discussions to highlight key points regarding diagnostic considerations, the anthrax vaccine, and the ultimate identification of the correct diagnosis.

Clinical features and outcome of acute disseminated encephalomyelitis (ADEM): An outlook from South India

Introduction: Acute disseminated encephalomyelitis (ADEM) is an uncommon inflammatory demyelinating encephalomyelitis that may follow infections, vaccinations or occur spontaneously. Most of the large series of this disorder were published in the pre-MRI era. Subsequently there has been a paucity of data regarding this entity. Aims: We sought to describe our experience with ADEM across 2 hospitals from Kerala, Sree chitra tirunal institute of medical sciences, thiruvanthapuram and the Indo-american Brain and spine center, Vaikom. We wanted to look at the clinico-radiological parameters of this patient population as well as the functional outcome following ADEM. Materials and Methods: A total of 45 patients seen in these two centers over a period of 9 years from 1995 to 2003 were analyzed in a retrospective-prospective design. MRI, CT scans, laboratory investigations, nerve conduction parameters and modified rankin outcome scores at last follow up were also noted. Results: The clinico-radiological profile of our patients was comparable to that of patients described in the literature. Relapse was uncommon although transient reappearance of prior symptoms during subsequent illness was common. Possible multiple sclerosis could be diagnosed only in one patient during follow up. Mortality was low ( Conclusions: ADEM deserves to be distinguished from MS in our population as there seems to be a low likelihood of recurrence or relapse. Although mortality rates have improved greatly, survivors are left with a plethora of disabilities and are functionally impaired. Future studies should focus on specific disabilities and treatment options to further improve outcomes in ADEM

Effect of Highly Active Antiretroviral Therapy on Multiple AIDS-defining Illnesses among Male HIV Seroconverters

The effect of highly active antiretroviral therapy (HAART) on multiple acquired immunodeficiency syndrome (AIDS)-defining illnesses remains unclear. Between 1984 and 2005, 573 male human immunodeficiency virus seroconverters in four US urban centers were followed for a median of 9.7 years. During follow-up, 345, 113, 50, and 65 men incurred 0, 1, 2, and >2 AIDS-defining illnesses, respectively. The authors extend the Cox proportional hazards model to determine whether the effect of HAART, as measured by calendar periods, persists beyond the first AIDS-defining illness. After adjustment for race and age at seroconversion, the hazards of a first through third AIDS-defining illness in the HAART calendar period (beyond July 1995) were 0.31 (95% confidence interval (CI): 0.21, 0.46), 0.39 (95% CI: 0.22, 0.74), and 0.33 (95% CI: 0.14, 0.79), respectively, relative to the monotherapy and combination therapy reference calendar period (January 1990-July 1995) and therefore did not attenuate with the number of prior AIDS-defining illnesses (p for homogeneity = 0.83). After the authors averaged over multiple AIDS-defining illnesses, the hazard of an AIDS-defining illness in the HAART calendar period was 0.34 (95% CI: 0.25, 0.45) relative to the reference calendar period. HAART protects against initial and subsequent AIDS-defining illnesses, whose inclusion in analysis markedly increased the precision of the estimated hazard ratio.