RESUMEN
- The Dutch College of General Practitioners' (NHG) practice guideline 'Urinary incontinence in women' provides guidelines for diagnosis and management of stress, urgency and mixed urinary incontinence in adult women.- General practitioners (GPs) should be alert to signals for urinary incontinence in women and offer active diagnosis and treatment if necessary.- Shared decision making is central in the guideline; the GP and the patient should discuss therapeutic options and decide on treatment policy in mutual consultation.- Women with stress urinary incontinence can choose between pelvic floor exercises or a pessary as initial treatment. Placing a midurethral sling (MUS) will be discussed if initial treatment is insufficiently effective or in the case of serious symptoms.- When bladder training is ineffective in urgency incontinence, the GP will discuss the pros and cons of adding an anticholinergic agent.- Exercise therapy can take place in the GPs practice or under supervision of a pelvic physical therapist.
Asunto(s)
Medicina General/métodos , Incontinencia Urinaria/diagnóstico , Incontinencia Urinaria/terapia , Adulto , Terapia por Ejercicio/métodos , Femenino , Médicos Generales , Humanos , Países Bajos , Sociedades Médicas , Cabestrillo SuburetralRESUMEN
OBJECTIVE: To study incidence rates of and risk factors for skin abscesses at the site of injection and episodes of endocarditis among injection drug users (IDU). DESIGN: A comprehensive, open cohort study of drug users on the natural history of human immunodeficiency virus (HIV) infection. METHODS: From 1986 to 1994, injection drug users in Amsterdam were included in the study. Incidence rates of self-reported skin abscesses and verified episodes of endocarditis were calculated. In uni- and multivariate Poisson regression analysis, risk factors for skin abscesses and endocarditis were determined. RESULTS: 521 HIV-seronegative and 237 HIV-seropositive IDU were followed for 1640 person-years. A total of 545 skin abscesses were reported by 269 IDU (incidence 33/100 person-years). HIV infection, female gender, prostitution among females, foreign nationality, injection of heroin and cocaine, a high frequency of injecting, and obtaining syringes through the needle exchange program were independently and positively associated with skin abscesses. During follow-up, 17 verified episodes of endocarditis were observed (incidence 1.3/100 person-years). Endocarditis was independently associated with HIV infection and a previous history of endocarditis. Furthermore, women and IDU with a skin abscess appeared to be at an increased risk for endocarditis. CONCLUSIONS: HIV infection is an independent risk factor for skin abscesses and endocarditis. Also, women are at an increased risk for these injection-related infections. Prevention activities, like promotion of skin cleaning, should be directed at those IDU in whom one or more risk factors have been identified.
Asunto(s)
Absceso/epidemiología , Endocarditis Bacteriana/epidemiología , Infecciones por VIH/complicaciones , Enfermedades Cutáneas Infecciosas/epidemiología , Abuso de Sustancias por Vía Intravenosa , Adulto , Femenino , Humanos , Incidencia , Masculino , Países Bajos/epidemiología , Estudios Prospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: To study the incidence and risk factors for pneumonia in a cohort of HIV infected and non-infected drug users (DU). DESIGN: A prospective epidemiological study. SETTING AND PATIENTS: Injecting and non-injecting DU who attended the Municipal Health Service in Amsterdam for follow-up visits in the study. MAIN RESULTS: 203 HIV infected and 437 non-infected DU were followed for a total of 1749 person-years. HIV infected DU reported 111 episodes of pneumonia, which required hospitalization in 29 cases, and HIV negative DU reported 55 episodes, which required hospitalization in nine cases. The incidences among HIV positive and HIV negative DU were 0.19 and 0.05 per person-year respectively. With multivariate Poisson regression current injecting (RR 2.13), recent seroconversion (RR 3.92), asthmatic constitution (RR 2.72), CD4+ cell count between 200-500 (RR 1.67 compared to > 500), CD4+ cell count less than 200 (RR 2.23 compared to > 500) and a previous history of pneumonia (RR 2.43) were independently associated with self-reported pneumonia among HIV infected DU. Among HIV negative DU heroin smoking (RR 1.87), asthmatic constitution (RR 3.62) and a previous history of pneumonia (RR 2.84) were independently associated with self-reported pneumonia. Also a higher Quetelet Index (QI) appeared to be protective (QI > or = 21 RR 0.42, QI 19-21 RR 0.82 compared to QI < 19) among HIV negative DU. Risk factors for reported and hospitalized cases of pneumonia were comparable among HIV positive DU. CONCLUSIONS: HIV infected DU are at increased risk for pneumonia and the rate increases with lower CD4 cell counts. Also behavioural characteristics, such as injecting drug use and smoking heroin, and clinical history variables, such as a history of pneumonia or an asthmatic constitution, are risk factors for pneumonia among DU. Pneumococcal vaccination should not only be focused on HIV positive DU but also on the identified risk groups among HIV negative DU.
Asunto(s)
Seropositividad para VIH/complicaciones , Neumonía/complicaciones , Trastornos Relacionados con Sustancias/complicaciones , Adulto , Recuento de Linfocito CD4 , Femenino , Heroína , Humanos , Incidencia , Masculino , Países Bajos/epidemiología , Neumonía/epidemiología , Estudios Prospectivos , Análisis de Regresión , Riesgo , Factores de RiesgoRESUMEN
The impact of human immunodeficiency virus (HIV) infection and other risk factors on mortality was studied in a cohort of Dutch injection drug users and drug users who did not inject. Participants were recruited between 1985 and 1992 and followed up through 1993. Vital status was ascertained through repeat visit information, supplemented by population register data. A total of 77 deaths were recorded among 632 drug users, for a mortality rate per 1,000 person-years of 7 for HIV-negative noninjection drug users, 18 for HIV-negative injection drug users, and 64 for HIV-positive injection drug users. In multivariate analyses, limited to injection drug users, a positive HIV serostatus, age above 40 years, and using benzodiazepines several times daily were significantly associated with an elevated risk of death, both for death from all causes and for death preceding acquired immunodeficiency syndrome (AIDS) diagnosis (pre-AIDS). For pre-AIDS death, the adjusted relative risk associated with HIV infection was 2.2 (95% confidence interval 1.3-3.7). Only 38% of HIV-infected injection drug users who died were diagnosed with AIDS. However, 76% of HIV-infected injection drug users who died without AIDS diagnosis had evidence of immunosuppression (CD4 count < 500/microliters). Daily use of methadone and participation in needle and syringe exchange schemes were not associated with lower mortality rates. This study illustrates in a group of injection drug users with a 30% HIV seroprevalence and a high background mortality the profound influence on mortality that HIV infection has gained.
Asunto(s)
Seronegatividad para VIH , Seropositividad para VIH/mortalidad , Abuso de Sustancias por Vía Intravenosa/mortalidad , Trastornos Relacionados con Sustancias/mortalidad , Adolescente , Adulto , Causas de Muerte , Comorbilidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Análisis Multivariante , Países Bajos/epidemiología , Vigilancia de la Población , Valor Predictivo de las Pruebas , Encuestas y Cuestionarios , Salud UrbanaRESUMEN
OBJECTIVE: To investigate whether notifying injecting drug users (IDU) of their positive HIV serostatus contributes to suicide and overdose mortality risk. DESIGN: Members of a cohort of IDU, recruited since December 1985, who first learned their HIV serostatus after study entry but before December 1992, were studied for incidence of deaths due to suicide and overdose. METHODS: Incidence of mortality due to suicide/overdose was calculated from date of first HIV test result disclosure until the end of follow-up or diagnosis of AIDS. RESULTS: Eighty-six HIV-positive and 252 HIV-negative IDU were included with median follow-up times of 4.3 and 4.0 years, respectively. Seven suicides and 10 deaths from overdose were recorded. High suicide/overdose risk shortly after test result notification was not found among HIV-positive IDU. Only one out of eight HIV-positive IDU who died of suicide/overdose died within 6 months of first disclosure. The overall suicide/overdose mortality rate was higher for HIV-positive than HIV-negative IDU; the rate ratio being 2.46 [95% confidence interval (CI), 0.95-6.39] or 2.04 (95% CI, 0.77-5.39) after control for confounders. CONCLUSIONS: Notifying IDU of their positive HIV serostatus does not appear to lead to a sudden and substantial rise in suicide/overdose deaths. Although death from suicide/overdose is more common among HIV-positive than HIV-negative IDU, this difference is likely to result from factors other than test result disclosure. Therefore, provided that appropriate counselling is offered, we see no reason to discourage voluntary HIV test result notification for fear of inducing suicide in HIV-infected IDU.
Asunto(s)
Serodiagnóstico del SIDA/psicología , Sobredosis de Droga/mortalidad , Seropositividad para VIH/complicaciones , Seropositividad para VIH/psicología , Abuso de Sustancias por Vía Intravenosa/complicaciones , Abuso de Sustancias por Vía Intravenosa/psicología , Suicidio , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Países Bajos/epidemiología , Factores de Tiempo , Revelación de la VerdadAsunto(s)
Infecciones por VIH/complicaciones , Infecciones por VIH/diagnóstico , VIH-1 , Abuso de Sustancias por Vía Intravenosa/complicaciones , Infecciones por VIH/virología , Seropositividad para VIH/complicaciones , Seropositividad para VIH/diagnóstico , VIH-1/genética , Humanos , Reacción en Cadena de la Polimerasa , Factores de TiempoAsunto(s)
Infecciones por VIH/inmunología , Recuento de Leucocitos , Complicaciones Posoperatorias/inmunología , Esplenectomía , Abuso de Sustancias por Vía Intravenosa/inmunología , Subgrupos de Linfocitos T , Linfocitos T CD4-Positivos , Estudios de Cohortes , Infecciones por VIH/complicaciones , Humanos , Bazo/lesiones , Abuso de Sustancias por Vía Intravenosa/complicaciones , Trombocitopenia/complicaciones , Trombocitopenia/cirugíaAsunto(s)
Linfocitos T CD4-Positivos/citología , Ritmo Circadiano , Infecciones por VIH/inmunología , Seronegatividad para VIH , Trastornos Relacionados con Sustancias/inmunología , Estudios de Cohortes , Estudios Transversales , Femenino , Infecciones por VIH/complicaciones , Humanos , Recuento de Leucocitos , Masculino , Análisis de Regresión , Trastornos Relacionados con Sustancias/complicacionesRESUMEN
OBJECTIVE: To study markers of progression in a cohort of HIV-infected intravenous drug users (IDU). DESIGN: A prospective epidemiologic study. SETTING AND PATIENTS: We studied progression of HIV infection among 126 IDU attending the Municipal Health Service in Amsterdam. MAIN OUTCOME MEASURES: Progression was defined as a decline of the CD4 cell count to < 200 x 10(6)/l on two consecutive follow-up visits or AIDS. RESULTS: Using Cox modelling, the following baseline variables were predictive of progression. Enhanced progression was associated with: age > 30 years [relative hazard (RH), 7.7 [95% confidence intervals (CI), 1.7-36.0]], core antibody negativity [RH, 5.3 (95% CI, 1.6-17.6)], CD4 cell count [for CD4 cells 350-500 x 10(6)/l, RH, 1.38 (95% CI, 0.37-5.16); for CD4 cells 200-350 x 10(6)/l, RH, 9.20 (95% CI, 2.73-31.05) compared with a CD4 count > 500 x 10(6)/l]. A lower rate of progression was associated with borrowing used injecting equipment. IDU who reported borrowing injecting equipment between 1980 and baseline 10-99 times or > 99 times had a RH of 0.44 (95% CI, 0.22-0.88) and 0.19 (95% CI, 0.03-0.37), respectively, compared with IDU who had borrowed < 10 times. p24 antigen positivity was more predictive than core antibody negativity in a model with time-dependent variables, the relative risk for p24 antigen-positive participants was 3.5 (95% CI, 1.3-9.3). Additional analysis of progression to AIDS in a larger group of IDU showed comparable results with regard to the effect of borrowing on progression. CONCLUSIONS: Our observation that those IDU who reported borrowing injecting equipment most frequently appeared to have the lowest rate of progression, corrected for some sources of potential confounding, requires further epidemiologic confirmation and extended laboratory studies since other sources of bias might have been present. Baseline CD4 count, age and core antibody or p24 antigen were predictive of progression in IDU. We wish to emphasize that our results do not imply that borrowing should be encouraged, but may have implications for our understanding of HIV pathogenesis.
Asunto(s)
Infecciones por VIH/fisiopatología , Compartición de Agujas , Abuso de Sustancias por Vía Intravenosa/complicaciones , Adulto , Estudios de Cohortes , Demografía , Femenino , Estudios de Seguimiento , Infecciones por VIH/complicaciones , Infecciones por VIH/epidemiología , Humanos , Incidencia , Recuento de Leucocitos , Masculino , Países Bajos/epidemiología , Prevalencia , Estudios Prospectivos , Abuso de Sustancias por Vía Intravenosa/epidemiología , Factores de TiempoRESUMEN
In the present study data on the incidence of HBV and HCV were used to indicate the prevalence of and trends in risk behavior, assuming that drug users (DUs) who become infected with HBV or HCV are also at risk for infection with HIV. In addition, we determined to that extent the transmission patterns of HIV, HBV and HCV differed. DUs were selected from a cohort study in Amsterdam, had at least one follow-up visit between December 1985 and September 1989 and reported never to have had homosexual contacts. Among 305 DUs, of whom 70% injected recently, the prevalence of HIV, HBV and HCV were 31%, 68% and 65% respectively. These prevalences were strongly interrelated and the same risk factors were found. The cumulative incidence of either HIV or HBV or HCV was 30% among prevalent HIV-negatives. Despite a previously reported reduction in risk behavior, only the HIV incidence tended to decrease initially, and after 1986 the incidences of HIV, HBV and HCV remained disturbingly high and stable (mean: 4, 9 and 10 per 100 person-years, respectively). As at present HBV appears to be transmitted more heterosexually than HIV in our study group and the HIV-epidemic may follow the HBV-epidemic in its transmission patterns, preventive activities targeted at both injecting and sexual behavior should be expanded.
Asunto(s)
Infecciones por VIH/epidemiología , Infecciones por VIH/transmisión , Hepatitis B/epidemiología , Hepatitis B/transmisión , Hepatitis C/epidemiología , Hepatitis C/transmisión , Vigilancia de la Población , Abuso de Sustancias por Vía Intravenosa/complicaciones , Adulto , Comorbilidad , Condones/estadística & datos numéricos , Femenino , Alemania/etnología , Infecciones por VIH/sangre , Infecciones por VIH/etiología , Infecciones por VIH/prevención & control , Hepatitis B/sangre , Hepatitis B/etiología , Hepatitis B/prevención & control , Hepatitis C/sangre , Hepatitis C/etiología , Hepatitis C/prevención & control , Homosexualidad , Humanos , Incidencia , Estudios Longitudinales , Masculino , Metadona/uso terapéutico , Compartición de Agujas , Países Bajos/epidemiología , Prevalencia , Factores de Riesgo , Trabajo Sexual , Conducta Sexual , Abuso de Sustancias por Vía Intravenosa/tratamiento farmacológico , Población UrbanaRESUMEN
OBJECTIVE: To study the clinical symptoms associated with seroconversion for HIV-1 among misusers of intravenous drugs. DESIGN: Case-control study in cohorts of drug misusers and homosexual men. SETTING: Outpatient clinic, Municipal Health Service, Amsterdam. SUBJECTS: Misusers of intravenous drugs from our prospective cohort who seroconverted for HIV. Controls were drug users positive for HIV, drug users negative for HIV, and homosexual men who had seroconverted. RESULTS: Five out of 18 (28%) drug users were admitted to hospital with bacterial pneumonia in the four to six months between their last visit at which they were HIV negative and their first visit when they were HIV positive. For comparison none of the 27 homosexual men who seroconverted for HIV, three out of 177 (2%) drug users negative for HIV, and 10 out of 112 (9%) drug users positive for HIV reported bacterial pneumonia. One out of the 18 drug users who seroconverted suffered from oesophageal candidiasis at the time of seroconversion. Other clinical symptoms did not differ between drug users who seroconverted and those who remained negative for HIV, probably due to the high background morbidity among the drug users. CONCLUSIONS: Seroconversion to HIV-1 among intravenous drug misusers is associated with bacterial pneumonia. Those drug users with previously negative test results for HIV who are admitted to hospital for bacterial pneumonia should be tested to detect primary infection with HIV-1.
Asunto(s)
Seropositividad para VIH/complicaciones , VIH-1/inmunología , Homosexualidad , Abuso de Sustancias por Vía Intravenosa/complicaciones , Infecciones Bacterianas/complicaciones , Estudios de Casos y Controles , Humanos , Masculino , Neumonía/complicaciones , Estudios Prospectivos , Abuso de Sustancias por Vía Intravenosa/inmunología , Factores de TiempoRESUMEN
We studied the prevalence and risk factors for thrombocytopenia among 299 drug users and 461 homosexual men. The prevalence of thrombocytopenia was 3.3% in HIV-negative homosexual men, 8.7% in HIV-negative drug users, 16.4% in HIV-positive homosexual men, and 36.9% in HIV-positive drug users. With multivariate logistic regression HIV-seropositivity (odds ratio 3.3), a history of injecting drugs (OR 3.9), an increased number of lymphocytes (OR 0.44), an increased number of neutrophils (OR 0.53) and a larger mean platelet volume (OR 2.8) were independently and significantly associated with thrombocytopenia. The results obtained with linear regression analysis were consistent with the results of the logistic regression. The higher prevalence of thrombocytopenia among drug users was related to a history of intravenous drug use but not to recent injecting. The mechanisms causing thrombocytopenia among HIV-positives and HIV-negatives seem to be related, but HIV-infection seems to enhance thrombocytopenia in an independent way.
Asunto(s)
Infecciones por VIH/complicaciones , Trastornos Relacionados con Sustancias/complicaciones , Trombocitopenia/epidemiología , Adulto , Estudios de Cohortes , Femenino , Infecciones por VIH/sangre , Homosexualidad , Humanos , Masculino , Recuento de Plaquetas , Prevalencia , Factores de Riesgo , Abuso de Sustancias por Vía Intravenosa/complicaciones , Trastornos Relacionados con Sustancias/sangre , Trombocitopenia/etiologíaRESUMEN
OBJECTIVE: To measure diurnal variation in the CD4 cell count and T-cell reactivity of drug users. DESIGN: A prospective epidemiological study among HIV-infected and non-infected drug users attending the Municipal Health Service of Amsterdam, The Netherlands. PATIENTS: Eleven HIV-infected and seven non-infected drug users. MAIN OUTCOME MEASURES: CD4 cell counts and T-cell reactivity three times a day. T-cell subsets and T-cell reactivity were determined from blinded samples within 2 hours. RESULTS: The number of CD4 cells increased by 130 x 10(6)/l (P < 0.05) in HIV-infected intravenous drug users over 8 hours. Following stimulation with anti-CD3 monoclonal antibodies, the T-cell reactivity of HIV-infected drug users rose from 118 to 221 c.p.m. (P < 0.01) over 8 hours. CD4 cell counts of the total study population increased by 37% and T-cell reactivity by 93%. The increase in the number of CD4 cells was more marked among active drug users than among drug users who had not used drugs recently. CONCLUSION: Variation in the CD4 cell count and in T-cell reactivity is large among drug users.
Asunto(s)
Linfocitos T CD4-Positivos , Ritmo Circadiano , Infecciones por VIH/sangre , Infecciones por VIH/complicaciones , Trastornos Relacionados con Sustancias/sangre , Trastornos Relacionados con Sustancias/complicaciones , Femenino , Infecciones por VIH/inmunología , Seropositividad para VIH/epidemiología , Humanos , Recuento de Leucocitos , Masculino , Trastornos Relacionados con Sustancias/inmunología , Linfocitos T/inmunologíaRESUMEN
OBJECTIVE: We determined pneumonia, endocarditis, hospitalizations and death rates in a group of HIV-infected and non-infected IVDU recruited at low-threshold methadone programmes in Amsterdam, The Netherlands to examine the influence of HIV infection on morbidity and non-AIDS mortality in intravenous drug users (IVDU) without AIDS. DESIGN: A prospective epidemiologic study among HIV-infected and non-infected IVDU in Amsterdam. SETTING: We analysed patients attending the Municipal Health Service of Amsterdam. PATIENTS: The patient group consisted of 197 HIV-seropositive IVDU and 193 HIV-seronegative IVDU as controls. MAIN OUTCOME MEASURES: We analysed incidence rates per person-year of bacterial pneumonia; hospitalizations and non-AIDS mortality; and relative risks for HIV-infected IVDU compared to non-infected IVDU. RESULTS: The incidence of bacterial pneumonia rose from 0.1 in 1986 to 0.29 in 1989 in HIV-infected IVDU. The overall relative risk for this group was 4.0 (95% confidence interval, 1.7-9.7) compared with non-infected controls. HIV-infected IVDU were more frequently hospitalized for bacterial pneumonia than non-infected IVDU (50 versus 13%). In contrast, non-AIDS mortality rates remained stable for both HIV-infected and non-infected IVDU. HIV seropositivity was not found to be an independent risk factor for non-AIDS mortality. CONCLUSION: We found a high and rising incidence of bacterial pneumonia among HIV-infected IVDU in Amsterdam without any consequential rise in non-AIDS mortality. This contrasts with reports from studies conducted in New York City, New York, USA, where bacterial pneumonia-related mortality has been found to increase markedly, coincident with the AIDS epidemic. Early detection of bacterial pneumonia and easy access to both inpatient and outpatient medical care may be important factors in preventing early death due to common bacterial pathogens in IVDU without AIDS.
Asunto(s)
Infecciones por VIH/complicaciones , Abuso de Sustancias por Vía Intravenosa/complicaciones , Adulto , Femenino , Estudios de Seguimiento , Infecciones por VIH/mortalidad , Seropositividad para VIH/complicaciones , Humanos , Masculino , Morbilidad , Países Bajos/epidemiología , Infecciones Oportunistas/epidemiología , Neumonía/epidemiología , Estudios Prospectivos , Abuso de Sustancias por Vía Intravenosa/mortalidadRESUMEN
To investigate whether drug use affected immunological parameters, we conducted a cross-sectional study of 321 drug users. Absolute numbers of CD4+ lymphocytes and the T-cell reactivity were lower in HIV-positive than in HIV-negative people. The functional capacity of the T-cell system as measured after stimulation with a monoclonal antibody directed against CD3 was found to be strongly associated with the frequency of injecting, while no relationship was found between the frequency of injecting and the total number of lymphocytes or T-cell subsets. HIV-negative and HIV-positive drug users who had injected a mean of three times a day in the preceding 4-6 months had a T-cell reactivity which was 40-50% lower compared with seronegative and with seropositive drug users who had not injected in the preceding months. We conclude that lymphocyte reactivity is depressed by frequent injecting in HIV-negative and HIV-positive drug users.