Asunto(s)
Registros Electrónicos de Salud/organización & administración , Uso Significativo/organización & administración , Planes de Incentivos para los Médicos , Médicos de Atención Primaria , Humanos , Medicare , Médicos de Atención Primaria/economía , Médicos de Atención Primaria/estadística & datos numéricos , Estados UnidosRESUMEN
This study examined the association between recent trends in CD4 and viral loads and cognitive test performance with the expectation that recent history could predict cognitive performance. Eighty-three human immunodeficiency virus (HIV)-infected patients with a mean CD4 count of 428 copies/ml were examined in this study (62% with undetectable plasma viral load [PVL]). We investigated the relationships between nadir CD4 cell count, 1-year trends in immunologic function/PVLs, and cognitive performance across several domains using linear regression models. Nadir CD4 cell count was predictive of current executive function (p = .004). One year clinical history for CD4 cell counts and/or PVLs were predictive of executive function, attention/working memory, and learning/memory measures (p < .05). Models that combined recent clinical history trends and nadir CD4 cell counts suggested that recent clinical trends were more important in predicting current cognitive performance for all domains except executive function. This research suggests that recent CD4 and viral load history is an important predictor of current cognitive function across several cognitive domains. If validated, clinical variables and cognitive dysfunction models may improve our understanding of the dynamic relationships between disease evolution and progression and CNS involvement.
Asunto(s)
Atención , Trastornos del Conocimiento/psicología , Función Ejecutiva , Infecciones por VIH/psicología , Adulto , Recuento de Linfocito CD4 , Trastornos del Conocimiento/complicaciones , Trastornos del Conocimiento/inmunología , Trastornos del Conocimiento/virología , Progresión de la Enfermedad , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/inmunología , Infecciones por VIH/virología , Humanos , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Análisis de Regresión , Carga ViralRESUMEN
Recent reports suggest that a growing number of human immunodeficiency virus (HIV)-infected persons show signs of persistent cognitive impairment even in the context of combination antiretroviral therapies (cART). The basis for this finding remains poorly understood as there are only a limited number of studies examining the relationship between CNS injury, measures of disease severity, and cognitive function in the setting of stable disease. This study examined the effects of HIV infection on cerebral white matter using quantitative morphometry of the midsagittal corpus callosum (CC) in 216 chronically infected participants from the multisite HIV Neuroimaging Consortium study currently receiving cART and 139 controls. All participants underwent MRI assessment, and HIV-infected subjects also underwent measures of cognitive function and disease severity. The midsagittal slice of the CC was quantified using two semi-automated procedures. Group comparisons were accomplished using ANOVA, and the relationship between CC morphometry and clinical covariates (current CD4, nadir CD4, plasma and CSF HIV RNA, duration of HIV infection, age, and ADC stage) was assessed using linear regression models. HIV-infected patients showed significant reductions in both the area and linear widths for several regions of the CC. Significant relationships were found with ADC stage and nadir CD4 cell count, but no other clinical variables. Despite effective treatment, significant and possibly irreversible structural loss of the white matter persists in the setting of chronic HIV disease. A history of advanced immune suppression is a strong predictor of this complication and suggests that antiretroviral intervention at earlier stages of infection may be warranted.
Asunto(s)
Complejo SIDA Demencia/patología , Fármacos Anti-VIH/administración & dosificación , Terapia Antirretroviral Altamente Activa , Cuerpo Calloso/patología , Infecciones por VIH/patología , VIH/fisiología , Imagen por Resonancia Magnética/métodos , Neuroimagen/métodos , Complejo SIDA Demencia/sangre , Complejo SIDA Demencia/etiología , Complejo SIDA Demencia/inmunología , Complejo SIDA Demencia/virología , Adulto , Recuento de Linfocito CD4 , Linfocitos T CD4-Positivos/inmunología , Estudios de Casos y Controles , Cognición , Cuerpo Calloso/efectos de los fármacos , Cuerpo Calloso/virología , Femenino , Infecciones por VIH/sangre , Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/inmunología , Infecciones por VIH/virología , Humanos , Terapia de Inmunosupresión/efectos adversos , Modelos Lineales , Estudios Longitudinales , Masculino , Persona de Mediana Edad , ARN Viral/sangre , Índice de Severidad de la Enfermedad , Carga Viral/fisiologíaRESUMEN
The automated volumetric output of FreeSurfer and Individual Brain Atlases using Statistical Parametric Mapping (IBASPM), two widely used and well published software packages, was examined for accuracy and consistency relative to auto-assisted manual (AAM) tracings (i.e., manual correction of automated output) when measuring the caudate, putamen, amygdala, and hippocampus in the baseline scans of 120 HIV-infected patients (86.7% male, 47.3+/-6.3y.o., mean HIV duration 12.0+/-6.3years) from the NIH-funded HIV Neuroimaging Consortium (HIVNC) cohort. The data was examined for accuracy and consistency relative to auto-assisted manual tracing, and construct validity was assessed by correlating automated and AAM volumetric measures with relevant clinical measures of HIV progression. When results were averaged across all patients in the eight structures examined, FreeSurfer achieved lower absolute volume difference in five, higher sensitivity in seven, and higher spatial overlap in all eight structures. Additionally, FreeSurfer results exhibited less variability in all measures. Output from both methods identified discrepant correlations with clinical measures of HIV progression relative to AAM segmented data. Overall, FreeSurfer proved more effective in the context of subcortical volumetry in HIV-patients, particularly in a multisite cohort study such as this. These findings emphasize that regardless of the automated method used, visual inspection of segmentation output, along with manual correction if necessary, remains critical to ensuring the validity of reported results.
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Encéfalo/patología , Infecciones por VIH/patología , Imagen por Resonancia Magnética/estadística & datos numéricos , Adulto , Algoritmos , Estudios de Cohortes , Interpretación Estadística de Datos , Progresión de la Enfermedad , Procesamiento Automatizado de Datos , Femenino , Infecciones por VIH/virología , Humanos , Procesamiento de Imagen Asistido por Computador , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Programas InformáticosRESUMEN
Proteinuria has been recognized in association with diabetes mellitus as early as the 18th century. This form of renal disease is known as diabetic nephropathy. It is now clear that diabetic nephropathy is the principal cause of end stage renal disease (ESRD) in the western world. According to reports by the United States Renal Data System (USRDS), in the past two decades there has been a continual increase in the incidence of ESRD among patients with diabetes. Many patients have diabetes that progresses to diabetic nephropathy, which is often not discovered until overt nephropathy is present. Many of the complications of diabetes could be minimized if patients received a comprehensive health maintenance program that includes vigorous cardiac risk reduction, routine eye examinations; routine foot examinations; screening and treatment for microalbuminuria, optimal hypertension management; and improved glycemic control. Hence, the key is not only prudent screening of these patients, but referral as well. Using a case study approach, this article illustrates the care of patients with diabetic nephropathy in type 1 diabetes mellitus.
Asunto(s)
Diabetes Mellitus Tipo 1/complicaciones , Nefropatías Diabéticas/diagnóstico , Nefropatías Diabéticas/terapia , Adulto , Cuidados Posteriores/organización & administración , Algoritmos , Atención Integral de Salud/organización & administración , Árboles de Decisión , Nefropatías Diabéticas/epidemiología , Nefropatías Diabéticas/etiología , Diagnóstico Diferencial , Dieta con Restricción de Proteínas , Progresión de la Enfermedad , Dislipidemias/complicaciones , Dislipidemias/prevención & control , Terapia por Ejercicio , Humanos , Hipertensión/complicaciones , Hipertensión/prevención & control , Fallo Renal Crónico/etiología , Masculino , Tamizaje Masivo , Educación del Paciente como Asunto , Proteinuria/etiología , Derivación y Consulta/organización & administración , Conducta de Reducción del Riesgo , Fumar/efectos adversos , Prevención del Hábito de Fumar , Negativa del Paciente al TratamientoRESUMEN
Acute renal failure related to exertional rhabdomyolysis is a medical condition that, if not diagnosed correctly and treated aggressively, can lead to serious dysfunction and may result in death. Although the history is invaluable in diagnosing this condition, it must be confirmed by laboratory testing. The sometimes subtle manifestations of exertional (nontraumatic) rhabdomyolysis make it mandatory that the health care team is able to recognize the signs and symptoms and understand the pathophysiology for prompt treatment and referral.