Acute Human Immunodeficiency Virus (HIV) Infection Presenting with Fever,Elevated Amylase/Lipase,and Hematologic Abnormalities

Background

Many cases of acute human immunodeficiency virus (HIV) infection (AHI) present to the Emergency Department (ED). Early diagnosis allows a patient to modify their behavior and seek early treatment. The Emergency Physician should know that the antibody response may be absent.

Objective

We report a case of AHI and review its presentation to increase the awareness of this important diagnosis.

Case Report

A 20-year-old black man who had a history of sex with men initially presented to the ED with a chief complaint of blood per rectum when he passed stool, and chills for the prior few days. His work-up was normal, including a rapid HIV screen, and he was discharged. He returned 2 weeks later with constipation, fatigue, myalgias, decreased urination, chills, and a productive cough. His physical examination was unremarkable, HIV antibody test was negative, but his laboratory tests showed an elevation of creatine phosphokinase, amylase, and lipase. His blood count showed a normal hematocrit and white blood cell count, but there were juvenile and vacuolated white cells and giant platelets reported. HIV viral load was reported as > 1,000,000 copies/mL.

Conclusions/Summary

This case illustrates that AHI can present as a non-specific illness. Patients at risk should be screened for HIV. However, AHI can occur before there is a significant antibody response. In such cases, a viral load test may help make the diagnosis, allowing for early treatment and patient counseling.     

Cultural perceptions and health behaviors related to safe motherhood among village women in Eastern Sudan: Ethnographic study

Background

Meeting the health needs of Sudanese women, especially those living in village areas, is imperative and cannot be accomplished without understanding the cultural perceptions and health behaviors related to safe motherhood. Nevertheless, there is little literature exploring these perspectives through qualitative study, as most of the studies performed in Sudan applied quantitative methods and focused on urban areas.

Objective

This study aims to explore cultural perceptions and behaviors relevant to safe motherhood among Sudanese village women.

Design/method

A qualitative method using an ethnographic approach was applied for the study. Semi-structured in-depth interviews were conducted with six village women of reproductive age living in a village in Gadarif State, Eastern Sudan.

Findings

The thematic content analysis revealed socio-economic factors, religious values and local beliefs shaping the village women's perceptions of their behaviors related to motherhood safety. Particular concerns included responses to health problems, preference for birth with traditional birth attendants, female genital mutilation/female genital cutting and a lack of utilizing family planning.

Conclusions

An implication arising from this study is that maternal services should develop a collaboration between village midwives and traditional birth attendants. This study further suggests that educational messages must be delivered to family relatives with consideration of the cultural influences highlighted by the village women.     

Hospitalizations of Older Patients with Human Immunodeficiency Virus in the United States

Background

Older adults represent a growing percentage of the United States (US) population living with human immunodeficiency virus (HIV). The Emergency Department plays an integral role in the identification and initial evaluation and treatment of patients with HIV.

Objective

We sought to estimate the number of hospitalizations of older adults (age ≥ 50 years) with HIV in the United States from 2000 to 2006 and compare features of this population to younger adults with HIV. Clinical and demographic characteristics of the younger cohort (19–49 years) and two older cohorts (ages 50–64 and ≥65 years) were examined and compared.

Methods

Data from the Nationwide Inpatient Sample was used to compare the three groups of HIV-positive patients. Comparisons between the most common discharge diagnoses and primary procedures were also made.

Results

Older adults with HIV constitute almost one quarter of the hospitalizations of adults with HIV. Older adults with HIV were more likely to be male, have a significantly higher average hospital charge, and have a longer length of stay than younger adults with HIV. Pneumonia and fluid and electrolyte disorders were common diagnoses among all three age cohorts.

Conclusions

Older HIV patients were more likely to die during hospitalization compared with younger adults with HIV and older adults without HIV. Admissions for older HIV patients almost doubled during the study period and future studies should examine whether this is due to aging of the current HIV population or new infections.     

Emergency department utilization among a cohort of HIV-positive injecting drug users in a Canadian setting

Background

Human immunodeficiency virus (HIV)-positive injection drug users (IDUs) are known to be at risk for multiple medical problems that may necessitate emergency department (ED) use; however, the relative contribution of HIV disease vs. injection-related complications has not been well described.

Objectives

We examined factors associated with ED use among a prospective cohort of HIV-positive IDUs in a Canadian setting.

Methods

We enrolled HIV-positive IDUs into a community-recruited prospective cohort study. We modeled factors associated with the time to first ED visit using Cox regression to determine factors independently associated with ED use. In sub-analyses, we examined ED diagnoses and subsequent hospital admission rates.

Results

Between December 5, 2005 and April 30, 2008, 428 HIV-positive IDUs were enrolled, among whom the cumulative incidence of ED use was 63.7% (95% confidence interval [CI] 59.1–68.3%) at 12 months after enrollment. Factors independently associated with time to first ED visit included: unstable housing (hazard ratio [HR] 1.5; 95% CI 1.1–2.0) and reporting being unable to obtain needed health care services (HR 2.2; 95% CI 1.2–4.1), whereas CD4 count and viral load were non-significant. Skin and soft tissue infections accounted for the greatest proportion of ED visits (17%). Of the 2461 visits to the ED, 419 (17%) were admitted to the hospital.

Conclusions

High rates of ED use were observed among HIV-positive IDUs, a behavior that was predicted by unstable housing and limited access to primary care. Factors other than HIV infection seem to be driving ED use among this population in the post-highly active antiretroviral therapy era.     

Depressive Symptoms in Women With Physical Disabilities: Identifying Correlates to Inform Practice

Objective

To examine correlates of depressive symptomatology in a sample of women with diverse physical disabilities to inform practice of modifiable risk factors that warrant attention and intervention.

Design

Interview survey.

Setting

Outpatient chronic care clinics.

Participants

Racially and ethnically diverse women (N=415) aged 18 to 64 years living with physical disabilities.

Interventions

Not applicable.

Main Outcome Measure

Center for Epidemiologic Studies Depression Scale.

Results

Depressive symptoms were high with more than half the women exceeding an established cutoff for clinically significant depressive symptomatology. In hierarchical multiple regression analyses, demographic, disability, and health variables explained significant variance in depressive symptoms; however, modifiable variables (pain interference, social support, abuse) contributed significantly to depression scores over and above demographic, disability, and health variables. Analyses examining predictors of depression classification revealed similar findings.

Conclusions

Depression is a significant problem for many women with physical disabilities. Modifiable contributors to depressive symptoms may provide intervention opportunities for researchers and clinicians. Clinicians need to attend closely to pain, particularly perceptions of pain interference; social support and social isolation; and abuse among women with physical disabilities. It may be valuable to include pain self-management, social networking and social skill development, and safety and abuse prevention training when designing depression intervention programs for this population.     

Reference Values and Psychometric Properties of the Lower Extremity Motor Coordination Test

Objectives

(1) To create predictive nomograms for the dominant and nondominant limbs on the Lower Extremity Motor Coordination Test (LEMOCOT) using reference values, and (2) to determine the inter- and intrarater reliability for the LEMOCOT; the best scoring method (first vs mean of the first 2 vs mean of the last 2 vs mean of 3 vs the highest of 3 trials); the best testing method (direct vs video observation); and the ability to detect real change (smallest real difference [SRD] and standard error of the measurement [SEM]).

Design

Normative and methodological study.

Setting

Metropolitan area.

Participants

Healthy individuals (N=320, 50% women) in 7 age groups: 20 to 29, 30 to 39, 40 to 49, 50 to 59, 60 to 69, 70 to 79, and ≥80 years. Each group had 50 participants, except for ≥80 years (n=20).

Interventions

Not applicable.

Main Outcome Measure

LEMOCOT.

Results

Age and sex explained 48% of the variance in the LEMOCOT scores for the dominant limb and 44% for the nondominant limb (125<F<148; P<.001). No significant differences were found regarding the different scoring methods (.12<F<1.02; .10<P<.92), and all of them demonstrated good reliability (intraclass correlation coefficients between .90 and .99; P<.001). There was agreement between scores from direct and video observation (limits of agreement −1.99 to 1.85; −1.55 to 1.62). Appropriate SEM (2.27–1.85) and SRD (6.27–5.11) values were found.

Conclusions

Reference values were determined for the LEMOCOT, and predictive nomograms were created based on age and sex. The LEMOCOT is reliable, needing only 1 trial (after familiarization) to generate reliable scores; can be scored from either direct or video observation; and has the ability to detect real change over time.     

A budget impact analysis of rapid human immunodeficiency virus screening in Veterans Administration emergency departments

Background

Human immunodeficiency virus (HIV) screening is cost-effective and recommended in populations with low disease prevalence. However, because screening is not cost-saving, its financial feasibility must be understood.

Study Objectives

We forecast the costs of two Emergency Department-based HIV testing programs in the Veterans Administration: 1) implementing a non-targeted screening program and providing treatment for all patients thusly identified (Rapid Testing); and 2) treating patients identified due to late-stage symptoms (Usual Care); to determine which program was the most financially feasible.

Methods

Using a dynamic decision-analysis model, we estimated the financial impact of each program over a 7-year period. Costs were driven by patient disease-severity at diagnosis, measured by CD4+ category, and the proportion of patients in each disease-severity category. Cost per CD4+ category was modeled from chart review and database analysis of treatment-naïve HIV-positive patients. Distributions of CD4+ counts differed in patients across the Rapid Testing and Usual Care arms.

Results

A non-targeted Rapid Testing program was not significantly more costly than Usual Care. Although Rapid Testing had substantial screening costs, they were offset by lower inpatient expenses associated with earlier identification of disease. Assuming an HIV prevalence of 1% and 80% test acceptance, the cost of Rapid Testing was $1,418,088, vs. $1,320,338 for Usual Care (p = 0.5854). Results support implementation of non-targeted rapid HIV screening in integrated systems.

Conclusions

This analysis adds a new component of support for HIV screening by demonstrating that rapid, non-targeted testing does not cost significantly more than a diagnostic testing approach.     

The role of HIV infection and drug and alcohol dependence in hospital mortality among critically ill patients

Purpose

Critical care outcomes among HIV-infected patients have improved because of advances in HIV therapy and general improvements in intensive care unit (ICU) management. There is a high co-occurrence of drug and alcohol dependence among HIV-infected patients, and the independent role of drug and alcohol dependence among patients with and without HIV infection in outcomes of critical illness is unclear.

Materials and methods

We analyzed a prospectively collected database of 7015 index ICU admissions at 2 teaching hospitals between January 1999 and January 2006. The ICU diagnoses were determined from prospective chart review and classified according to the dictionary of diagnoses developed by the Intensive Care National Audit and Research Council. We used logistic regression to determine the independent association of drug and alcohol dependence as well as HIV infection with in-hospital mortality. Covariates that were adjusted for included acute drug overdose, Acute Physiology and Chronic Health Evaluation II score, age, sex, hospital site, and socioeconomic variables.

Results

Of all patients, 4.4% (309 of 7015) were HIV infected; and of these, 56% (173 of 309) had a history of drug and alcohol dependence, whereas only 7.4% (502 of 6706) of the HIV-negative group had a history of drug and alcohol dependence. Drug and alcohol dependence was not independently associated with hospital mortality in either the model including all admissions (adjusted odds ratio [AOR] 0.80; 95% confidence interval [CI] 0.62-1.03) or the model including pneumonia and sepsis admissions only (AOR 0.92; 95% CI 0.59-1.41). Infection with HIV was independently associated with hospital mortality (AOR 2.16; 95% CI 1.60-2.93).

Conclusions

Although HIV infection is associated with increased hospital mortality, drug and alcohol dependence is not associated with an increased hospital mortality independent of HIV infection.     

Experience of persistent psychological symptoms and perceived stigma among people with HIV on antiretroviral therapy (ART): A systematic review

Background

Advances in HIV care have resulted in increasing numbers of HIV patients receiving antiretroviral therapy and achieving viral control. This has led to a focus on the biomedical aspects of care, leaving the data on psychological and social problems relatively neglected; in fact they have never before been systematically reviewed. If present and unmanaged, psychological and social problems are associated with unnecessary suffering and non-adherence to medication, with potentially serious clinical and public health consequences.

Objective

To assess the prevalence of depression and anxiety reported in the literature, and the presence or absence of the experience of stigma among HIV positive people on antiretroviral therapy.

Design and review methods

A systematic review in line with PRISMA guidelines. The prevalence data from retained studies were analysed by study location and data quality.

Data sources

Five databases were systematically searched (Embase, PsychINFO, MEDLINE and British Nursing index and Web of Science) from 1996 (first availability of highly effective antiretroviral therapy) to August 2013 using a predefined search strategy.

Results

Sixty-six original studies identified the prevalence of depression, anxiety and presence or absence of the experience of stigma. The mean point prevalence of depression was 33.60% (SD 19.47) with lower reported point prevalence in high income countries (25.81% (15.21)) compared to low and middle income countries (41.36% (21.42)). The one-to four-week period prevalence of depression was 39.79% (21.52), similar in high income countries and low and middle income countries. The point prevalence of anxiety was 28.38% (17.07), with a higher prevalence in low and middle income countries (33.92% (10.64)) compared with high income countries (21.53% (22.91)) with wide variability. The mean point prevalence of stigma was 53.97% (22.06) and 1 year period prevalence 52.11% (25.57). Heterogeneity in both sampling and methodology prevented meta-analysis of this data.

Conclusion

HIV positive patients on antiretroviral therapy report a higher prevalence of depression and anxiety than the general population, which nursing assessment and practice should address. Over half of HIV positive people report experiencing stigma. The difficulties with heterogeneous studies should be addressed through the development of a cross-culturally validated, multidimensional assessment tool in this population, and an increase in data disaggregated by risk groups.     

“A mixture of positive and negative feelings”: A qualitative study of primary care midwives’ experiences with non-western clients living in the Netherlands

Background

Non-western women living in the Netherlands are diverse in origin, which implies diversity in their needs and expectations for midwifery care. Furthermore, it has also been shown that non-western women make suboptimal use of prenatal care. Midwives may therefore face difficulties when caring for these clients.

Objective

The main objective of our study was to explore Dutch primary care midwives’ experiences with non-western clients.

Methods

A qualitative design was used. Thirteen midwives were interviewed individually and 8 participated in a focus group. All interviews were transcribed and analysed by two researchers who compared and discussed their results. Analytical codes were organised into subthemes and main themes.

Results

Midwives perceived ethnic diversity as both difficult and interesting. Caring for these women was perceived as demanding, but also rewarding. They experienced a variety of difficulties when caring for these women: communication problems, suboptimal health literacy, socioeconomic problems, lack of knowledge of the maternity care system, pressure from the family and a strong preference for physicians. In spite of these difficulties, midwives aim for optimal care by being alert and proactive, taking these women by the hand and making use of alternative resources.

Conclusion

Provision of care to non-western clients can be difficult and may require additional measures. These problems and measures should be included in midwifery education programmes as well as training programmes for midwives.     

Are online support groups always beneficial? A qualitative exploration of the empowering and disempowering processes of participation within HIV/AIDS-related online support groups

Background

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is one of the leading concerns in healthcare. Individuals living with HIV/AIDS are often confronted with tremendous physical and psychosocial challenges. Online support groups can provide a valuable source of information, advice and support, and a medium through which individuals living with HIV/AIDS can interact with each other and share their experiences. However, very little is known about how online support group might promote empowerment and the potential disadvantages associated with online support group use among individuals living with HIV/AIDS.

Objectives

The present study explored the potential empowering and disempowering processes, and empowering outcomes of online support group use among individuals with HIV/AIDS.

Design, settings, participants

A total of 115 HIV-positive online support group members were recruited from HIV-related online support groups. They completed an online survey exploring their experiences of online support group use.

Results

Thematic analysis revealed six empowering processes arising from use of online support groups: exchanging information, sharing experiences, connecting to others, encountering emotional support, finding recognition and understanding, and helping others. Six empowering outcomes were identified: increased optimism, emotional well-being, social well-being, being better informed, improved disease management, and feeling confident in the relationship with physicians. Potentially disempowering processes were also identified which included: being unable to connect physically, inappropriate behaviour online, declining real life relationships, and information overload and misinformation.

Conclusion

Findings suggest ways through which individuals with HIV/AIDS may be empowered although some problematic features specific to the online context may also be present.     

Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review

Background

Diastasis of the rectus abdominis muscle (DRAM) is common during and after pregnancy, and has been related to lumbopelvic instability and pelvic floor weakness. Women with DRAM are commonly referred to physiotherapists for conservative management, but little is known about the effectiveness of such strategies.

Objectives

To determine if non-surgical interventions (such as exercise) prevent or reduce DRAM.

Data sources

EMBASE, Medline, CINAHL, PUBMED, AMED and PEDro were searched.

Study selection/eligibility

Studies of all designs that included any non-surgical interventions to manage DRAM during the ante- and postnatal periods were included.

Study appraisal and synthesis methods

Methodological quality was assessed using a modified Downs and Black checklist. Meta-analysis was performed using a fixed effects model to calculate risk ratios (RR) and 95% confidence intervals (CI) where appropriate.

Results

Eight studies totalling 336 women during the ante- and/or postnatal period were included. The study design ranged from case study to randomised controlled trial. All interventions included some form of exercise, mainly targeted abdominal/core strengthening. The available evidence showed that exercise during the antenatal period reduced the presence of DRAM by 35% (RR 0.65, 95% CI 0.46 to 0.92), and suggested that DRAM width may be reduced by exercising during the ante- and postnatal periods.

Limitations

The papers reviewed were of poor quality as there is very little high-quality literature on the subject.

Conclusion and implications

Based on the available evidence and quality of this evidence, non-specific exercise may or may not help to prevent or reduce DRAM during the ante- and postnatal periods.     

Effects of Age and Gender on Dynamic Stability During Stair Descent

Objective

To determine the effects of age and sex and their interaction effects on dynamic postural stability during stair descent.

Design

Cross sectional.

Setting

Laboratory.

Participants

Healthy younger adults (N=28) and healthy older adults (N=21).

Interventions

Not applicable.

Main Outcome Measures

Spatiotemporal gait parameters, displacement of center of mass (COM), instantaneous velocity of the COM, divergence between vertical projection of the COM, and center of pressure (COP).

Results

Interaction effects of age and sex were found in stride duration, COM displacement, and instantaneous velocity of the COM in the mediolateral direction. Older adults demonstrated longer stride duration with shorter double-limb stance and longer single-limb stance during stair descent. Women have significantly longer stride duration than men. The effects of sex and age were significant in the data normalized by height. Older adults and women demonstrated larger peak-to-peak COM displacement, peak instantaneous velocity of the COM, and COM-COP divergence than the younger individuals and men, respectively. Peak instantaneous velocity of the COM was significant different in most pairwise comparisons, but the COM-COP divergence was significantly different in several comparisons.

Conclusions

This study examined the COM and COP parameters to quantify dynamic stability during stair descent across sex and age. Although older women descended stairs successfully, they demonstrated differences in control of instantaneous velocity of the COM compared with the other participants. Dynamic instability could be detected by examining the control of instantaneous velocity of the COM. In developing a better understanding of the balance control of stair descent in healthy older adults, aging patients with various pathologies can be better assessed, appropriately treated, and provided with proper assistive devices.     

A Depressed Post-Menopausal Woman

Background

Post-menopausal women are at significant risk for coronary artery disease, have increased rates of depression compared to their male counterparts, and often present atypically with coronary insufficiency. The symptoms of depression and coronary ischemia overlap greatly. Complaints like fatigue, body aches, and sleep disturbance reported by a depressed elderly woman may be cardiac related and need to be investigated seriously without physician bias.

Objectives

To ensure that clinicians are cautious when evaluating older women with a history of depression who are presenting with atypical complaints.

Case Report

A 61-year-old woman with history of depression presented to the Emergency Department with multiple complaints atypical for acute coronary syndrome. She had an immediate electrocardiogram and troponin-T Biosite point-of-care test (Biosite Incorporated, San Diego, CA) performed, which were positive for cardiac ischemia and myocardial infarction. The patient underwent immediate cardiac catheterization, which revealed occlusion of the mid left circumflex. After aspiration of thrombus and balloon dilatation of the site, a bare metal stent was deployed, restoring excellent flow. The patient did well medically but her depression worsened after the procedure and continues despite psychiatric intervention.

Conclusion

For years there have been gender differences in medical treatment of coronary artery disease, and often women’s complaints are not investigated aggressively. Post-menopausal women are at great risk for cardiac ischemia and depression, and their symptoms, which are often atypical, may not be diagnosed as anginal equivalents. In addition, depression is an independent risk factor for cardiovascular disease and, if it occurs after myocardial infarction, may lead to poor quality of life and increased morbidity and mortality. Patients who have had a coronary event must be thoroughly evaluated for signs of depression and receive the necessary treatment.     

The incidence of and risk factors for HIV-associated cognitive–motor complex among patients on HAART

Background

While highly active antiretroviral therapy (HAART) allows for the considerable decline in the incidence of HIV-related opportunistic infections and tumors, its effect on treating HIV infection of the brain, such as HIV-associated dementias (HADs), remains unclear.

Methods

A cross-sectional study of consecutive series of 96 patients from the Serbian HIV/AIDS cohort, treated with HAART in our HIV unit was performed to evaluate the incidence of and risk factors for cognitive/motor complex during HAART. CD4 + T cell counts and pVL values at the time of neurological evaluation were parameters of the response to HAART. The mini-mental test and neurologic examination were performed at one point of time during treatment to reveal cognitive and/or motor disorders.

Results

After mean HAART duration of 47 months, unimpaired cognition, minor cognitive impairment, and HIV-associated dementia were recorded in 56 (58.3%), 27 (28.1%), and 13 (13.5%), respectively. Motor abnormalities had 39 (40.6%) patients. Of these, 21, 12, and 6 patients belong to the subgroups with normal cognition, minor cognitive impairment and HAD patients, respectively. Factors predictive for HAD were age over 40 (OR 3.7, 95% CI 1.07–13.28, P = 0.039), and AIDS diagnosis prior to HAART initiation (OR 14.19, 95% CI 1.76–114.16, P = 0.013). Conversely, factors shown to be protective against HAD were the usage of AZT and NNRTIs, as components of HAART regimens (OR 0.18, 95% CI 0.046–0.76, P = 0.019, and OR 0.14, 95% CI 0.034–0.6, P = 0.008).

Conclusion

Cognitive/motor complex has still remained a significant neuropathology among late presenters and elder HIV/AIDS patients. Certain HAART regimens containing AZT, and/or NNRTIs, could be protective for these patients.     

Status disclosure and the acceptance of women living with HIV

Objective

This study aimed at identifying the acceptance of women living with HIV in relation to status disclosure.

Relationship between the paraoxonase 1 gene glutamine 192 to arginine polymorphism and gestational diabetes mellitus in Saudi women

Objectives

Gestational diabetes mellitus (GDM) is recognized as an imbalance between insulin resistance and insulin secretion, leading to maternal hyperglycemia. Previous studies in a Saudi population indicated a high frequency of Paraoxonase 1 glutamine 192 to arginine (PON1 Q192R) polymorphism, suggesting this polymorphism as an additional risk factor. The present study was designed to explore the possible association between the PON1 Q192R polymorphism and GDM in a Saudi population.

Methods

This case–control study was carried out in 500 pregnant women, including 200 GDM cases and 300 non-GDM women. Genotyping for PON1 Q192R (rs662) variants was performed by polymerase chain reaction–restriction fragment length polymorphism (PCR–RFLP).

Results

The results of the present study indicates that Q192R polymorphism was significantly associated with GDM in a Saudi population with the minor allele frequency (MAF) (p = 0.0007). Q192R genotypes and alleles showed a strong association with GDM (p = 0.009 and p = 0.0007, respectively).

Conclusion

In conclusion, these findings suggest that the PON1 Q192R polymorphism has high MAF in GDM in the studied Saudi population.