RESUMEN

BACKGROUND: This is the second update of the original Cochrane review published in 2013 (issue 6), which was updated in 2016 (issue 11). Pruritus occurs in patients with disparate underlying diseases and is caused by different pathologic mechanisms. In palliative care patients, pruritus is not the most prevalent but is a burdening symptom. It can cause considerable discomfort and negatively affect patients' quality of life. OBJECTIVES: To assess the effects of different pharmacological treatments compared with active control or placebo for preventing or treating pruritus in adult palliative care patients. SEARCH METHODS: For this update, we searched CENTRAL (the Cochrane Library), MEDLINE (OVID) and Embase (OVID) up to 6 July 2022. In addition, we searched trial registries and checked the reference lists of all relevant studies, key textbooks, reviews and websites, and we contacted investigators and specialists in pruritus and palliative care regarding unpublished data. SELECTION CRITERIA: We included randomised controlled trials (RCTs) assessing the effects of different pharmacological treatments, compared with a placebo, no treatment, or an alternative treatment, for preventing or treating pruritus in palliative care patients. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the identified titles and abstracts, performed data extraction and assessed the risk of bias and methodological quality. We summarised the results descriptively and quantitatively (meta-analyses) according to the different pharmacological interventions and the diseases associated with pruritus. We assessed the evidence using GRADE and created 13 summary of findings tables. MAIN RESULTS: In total, we included 91 studies and 4652 participants in the review. We added 42 studies with 2839 participants for this update. Altogether, we included 51 different treatments for pruritus in four different patient groups. The overall risk of bias profile was heterogeneous and ranged from high to low risk. The main reason for giving a high risk of bias rating was a small sample size (fewer than 50 participants per treatment arm). Seventy-nine of 91 studies (87%) had fewer than 50 participants per treatment arm. Eight (9%) studies had low risk of bias in the specified key domains; the remaining studies had an unclear risk of bias (70 studies, 77%) or a high risk of bias (13 studies, 14%). Using GRADE criteria, we judged that the certainty of evidence for the primary outcome (i.e. pruritus) was high for kappa-opioid agonists compared to placebo and moderate for GABA-analogues compared to placebo. Certainty of evidence was low for naltrexone, fish-oil/omega-3 fatty acids, topical capsaicin, ondansetron and zinc sulphate compared to placebo and gabapentin compared to pregabalin, and very low for cromolyn sodium, paroxetine, montelukast, flumecinol, and rifampicin compared to placebo. We downgraded the certainty of the evidence mainly due to serious study limitations regarding risk of bias, imprecision, and inconsistency. For participants suffering from uraemic pruritus (UP; also known as chronic kidney disease (CKD)-associated pruritus (CKD-aP)), treatment with GABA-analogues compared to placebo likely resulted in a large reduction of pruritus (visual analogue scale (VAS) 0 to 10 cm): mean difference (MD) -5.10, 95% confidence interval (CI) -5.56 to -4.55; five RCTs, N = 297, certainty of evidence: moderate. Treatment with kappa-opioid receptor agonists (difelikefalin, nalbuphine, nalfurafine) compared to placebo reduced pruritus slightly (VAS 0 to 10 cm, MD -0.96, 95% CI -1.22 to -0.71; six RCTs, N = 1292, certainty of evidence: high); thus, this treatment was less effective than GABA-analogues. Treatment with montelukast compared to placebo may result in a reduction of pruritus, but the evidence is very uncertain (two studies, 87 participants): SMD -1.40, 95% CI -1.87 to -0.92; certainty of evidence: very low. Treatment with fish-oil/omega-3 fatty acids compared to placebo may result in a large reduction of pruritus (four studies, 160 observations): SMD -1.60, 95% CI -1.97 to -1.22; certainty of evidence: low. Treatment with cromolyn sodium compared to placebo may result in a reduction of pruritus, but the evidence is very uncertain (VAS 0 to 10 cm, MD -3.27, 95% CI -5.91 to -0.63; two RCTs, N = 100, certainty of evidence: very low). Treatment with topical capsaicin compared with placebo may result in a large reduction of pruritus (two studies; 112 participants): SMD -1.06, 95% CI -1.55 to -0.57; certainty of evidence: low. Ondansetron, zinc sulphate and several other treatments may not reduce pruritus in participants suffering from UP. In participants with cholestatic pruritus (CP), treatment with rifampicin compared to placebo may reduce pruritus, but the evidence is very uncertain (VAS: 0 to 100, MD -42.00, 95% CI -87.31 to 3.31; two RCTs, N = 42, certainty of evidence: very low). Treatment with flumecinol compared to placebo may reduce pruritus, but the evidence is very uncertain (RR > 1 favours treatment group; RR 2.32, 95% CI 0.54 to 10.1; two RCTs, N = 69, certainty of evidence: very low). Treatment with the opioid antagonist naltrexone compared to placebo may reduce pruritus (VAS: 0 to 10 cm, MD -2.42, 95% CI -3.90 to -0.94; two RCTs, N = 52, certainty of evidence: low). However, effects in participants with UP were inconclusive (percentage of difference -12.30%, 95% CI -25.82% to 1.22%, one RCT, N = 32). In palliative care participants with pruritus of a different nature, the treatment with the drug paroxetine (one study), a selective serotonin reuptake inhibitor, compared to placebo may reduce pruritus slightly by 0.78 (numerical analogue scale from 0 to 10 points; 95% CI -1.19 to -0.37; one RCT, N = 48, certainty of evidence: low). Most adverse events were mild or moderate. Two interventions showed multiple major adverse events (naltrexone and nalfurafine). AUTHORS CONCLUSIONS: Different interventions (GABA-analogues, kappa-opioid receptor agonists, cromolyn sodium, montelukast, fish-oil/omega-3 fatty acids and topical capsaicin compared to placebo) were effective for uraemic pruritus. GABA-analogues had the largest effect on pruritus. Rifampin, naltrexone and flumecinol tended to be effective for cholestatic pruritus. However, therapies for patients with malignancies are still lacking. Due to the small sample sizes in most meta-analyses and the heterogeneous methodological quality of the included trials, the results should be interpreted cautiously in terms of generalisability.

Asunto(s)

Capsaicina , Cuidados Paliativos , Animales , Humanos , Cromolin Sódico , Ácido gamma-Aminobutírico , Naltrexona , Ondansetrón , Paroxetina , Receptores Opioides , Rifampin , Sulfato de Zinc

RESUMEN

INTRODUCTION: Although raltegravir has been available since 2007, data are lacking on the Portuguese population living with HIV who initiated this antiretroviral therapy. Hence, this study aimed to characterize the patients who initiated raltegravir-based regimens between January 2015 and December 2017, on sociodemographics, clinical features, and treatment satisfaction. MATERIAL AND METHODS: Observational, retrospective, multicentre study conducted at 11 reference sites. Sociodemographic and clinical data were collected retrospectively from hospital medical records. For participants continuing raltegravir at study inclusion, the HIV Treatment Satisfaction Questionnaire was administered to assess satisfaction with raltegravir-based therapy. Descriptive statistics were performed. Treatment-naïve and treatment-experienced subgroups were compared for demographic and clinical variables. RESULTS: A total of 302 patients were included; mostly men (69.5%) with a mean age of 49 years old. Approximately half of the patients had at least one non-AIDS-related comorbidity at baseline (53.3%), such as hypercholesterolemia, arterial hypertension, diabetes mellitus, and depression. Moreover, 52.3% were treatment-experienced patients with up to two treatments prior to raltegravir. Across the study time points, there was a reduction in the viral load and improvement in CD4 counts in both the treatment-naïve and treatment-experienced subgroups. Continuing users of raltegravir reported high treatment satisfaction (55.4 ± 7.2 points). CONCLUSION: Raltegravir-based regimens seem like a valid therapeutic option in heterogeneous populations of HIV-infected patients, in patients with previous ART experience and as part of first-line therapeutic options alongside with the latest generation of drugs from its class.

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Introdução: Apesar de o raltegravir estar disponível desde 2007, os dados na população portuguesa com VIH que iniciou esta terapêutica antirretroviral são escassos. Deste modo, este estudo teve por objetivo caracterizar os doentes que iniciaram um regime terapêutico baseado em raltegravir entre janeiro de 2015 e dezembro de 2017, relativamente a dados sociodemográficos, características clínicas e satisfação com o tratamento. Material e Métodos: Estudo observacional, retrospetivo, multicêntrico conduzido em 11 centros de referência. Os dados sociodemográficos e clínicos foram recolhidos retrospetivamente nos processos clínicos. Os participantes que continuaram o regime com raltegravir após a inclusão no estudo preencheram o HIV Treatment Satisfaction Questionnaire para avaliar a satisfação com a terapêutica. Foram efetuadas análises de estatística descritiva e comparações para as variáveis sociodemográficas e clínicas nos subgrupos de doentes naïve de tratamento e de doentes com experiência terapêutica. Resultados: Foram incluídos 302 doentes, maioritariamente do sexo masculino (69,5%) com idade média de 49 anos. Aproximadamente metade dos doentes tinha pelo menos uma comorbilidade não relacionada com SIDA no início do estudo (53,3%), tais como hipercolesterolemia, hipertensão arterial, diabetes mellitus ou depressão. Adicionalmente, 52,3% eram doentes com experiência terapêutica com até dois tratamentos anteriores ao raltegravir. Ao longo do estudo verificou-se uma redução na carga viral e uma melhoria nas contagens de CD4 em ambos os subgrupos de doentes (doentes naïve de tratamento e doentes com experiência terapêutica). Os doentes com uso continuado de raltegravir reportaram uma elevada satisfação com o tratamento (55,4 ± 7,2 pontos). Conclusão: Os regimes terapêuticos baseados em raltegravir parecem ser uma opção terapêutica válida em populações heterogéneas de doentes infetados com VIH, em doentes com experiência em ART e como tratamento de primeira linha, em paralelo com outras terapêuticas de última geração.

Asunto(s)

Infecciones por VIH , Masculino , Humanos , Persona de Mediana Edad , Femenino , Raltegravir Potásico/uso terapéutico , Raltegravir Potásico/efectos adversos , Estudios Retrospectivos , Portugal , Carga Viral , Infecciones por VIH/tratamiento farmacológico

RESUMEN

BACKGROUND: Regular methamphetamine (MA) use can result in withdrawal syndrome characterized by fatigue, agitation, depression, and anxiety. No studies that we are aware of have examined the prevalence and predictors of MA withdrawal symptoms among people who inject drugs (PWID). METHODS: PWID were recruited using targeted sampling methods in Los Angeles and San Francisco, California from 2016 to 2017. Survey questions included demographics, drug use, and MA withdrawal symptoms, frequency, and symptom severity. Participants who reported regular MA use (> 12 times in the last 30 days) were included in this analysis (N = 595). Multivariable regression models were developed to examine factors associated with any MA withdrawal, withdrawal frequency, symptom severity, and receptive syringe sharing. RESULTS: MA withdrawal symptoms in the past 6 months were reported by 53 % of PWID, with 25 % reporting weekly withdrawal symptoms, and 20 % reporting very or extremely painful symptoms. In multivariable logistic regression, presence of any MA withdrawal symptoms was positively associated with more frequent MA use and non-injection tranquilizer use and inversely associated with crack cocaine use. Among those reporting any withdrawal, female sex was associated with more frequent withdrawal symptoms. Very or extremely painful withdrawal symptoms were associated with being in residential treatment. Receptive syringe sharing was associated with any MA withdrawal symptoms and weekly frequency of symptoms. CONCLUSION: MA withdrawal symptoms are common among PWID and are associated with receptive syringe sharing. Strategies for implementing MA use treatment, safe supply programs, and syringe services programs targeting people who inject MA are indicated.

Asunto(s)

Infecciones por VIH , Metanfetamina , Preparaciones Farmacéuticas , Abuso de Sustancias por Vía Intravenosa , Síndrome de Abstinencia a Sustancias , Femenino , Humanos , Metanfetamina/efectos adversos , Compartición de Agujas , Asunción de Riesgos , Abuso de Sustancias por Vía Intravenosa/epidemiología , Síndrome de Abstinencia a Sustancias/diagnóstico , Síndrome de Abstinencia a Sustancias/epidemiología

RESUMEN

OBJECTIVE: Opioid withdrawal symptoms are widely understood to contribute to health risk but have rarely been measured in community samples of opioid using people who inject drugs (PWID). METHODS: Using targeted sampling methods, 814 PWID who reported regular opioid use (at least 12 uses in the last 30 days) were recruited and interviewed about demographics, drug use, health risk, and withdrawal symptoms, frequency, and pain. Multivariable regression models were developed to examine factors associated with any opioid withdrawal, withdrawal frequency, pain severity, and two important health risks (receptive syringe sharing and non-fatal overdose). RESULTS: Opioid withdrawal symptoms were reported by 85 % of participants in the last 6 months, with 29 % reporting at least monthly withdrawal symptoms and 35 % reporting at least weekly withdrawal symptoms. Very or extremely painful symptoms were reported by 57 %. In separate models, we found any opioid withdrawal (adjusted odds ratio [AOR] = 2.75, 95 % confidence interval [CI] = 1.52, 5.00) and weekly or more opioid withdrawal frequency (AOR = 1.94; 95 % CI = 1.26, 3.00) (as compared to less than monthly) to be independently associated with receptive syringe sharing while controlling for confounders. Any opioid withdrawal (AOR = 1.71; 95 % CI = 1.04, 2.81) was independently associated with nonfatal overdose while controlling for confounders. In a separate model, weekly or more withdrawal frequency (AOR = 1.69; 95 % CI = 1.12, 2.55) and extreme or very painful withdrawal symptoms (AOR = 1.53; 95 % CI = 1.08, 2.16) were associated with nonfatal overdose as well. CONCLUSIONS: Withdrawal symptoms among PWID increase health risk. Treatment of withdrawal symptoms is urgently needed and should include buprenorphine dispensing.

Asunto(s)

Analgésicos Opioides/efectos adversos , Estado de Salud , Trastornos Relacionados con Opioides/epidemiología , Dolor/epidemiología , Abuso de Sustancias por Vía Intravenosa/epidemiología , Síndrome de Abstinencia a Sustancias/epidemiología , Adulto , Analgésicos Opioides/uso terapéutico , Buprenorfina/uso terapéutico , Estudios Transversales , Sobredosis de Droga/tratamiento farmacológico , Sobredosis de Droga/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Compartición de Agujas/tendencias , Trastornos Relacionados con Opioides/tratamiento farmacológico , Dolor/tratamiento farmacológico , Factores de Riesgo , Abuso de Sustancias por Vía Intravenosa/tratamiento farmacológico , Síndrome de Abstinencia a Sustancias/tratamiento farmacológico

RESUMEN

Lin and colleagues presented an unusual case of AIDS-related cholecystopathy with an enlarged gallbladder and thickened wall. Cholecystopathy is a rare condition characterized by biliary abnormalities in AIDS patients, and the mechanism remains unclear. The authors aimed to heighten awareness of this entity in patients with advanced AIDS disease status.

Asunto(s)

Síndrome de Inmunodeficiencia Adquirida/complicaciones , Enfermedades de la Vesícula Biliar/diagnóstico por imagen , Enfermedades de la Vesícula Biliar/etiología , Diagnóstico Diferencial , Femenino , Humanos , Persona de Mediana Edad

RESUMEN

BACKGROUND: The efficacy of licensed direct-acting antiviral (DAA) regimens is assumed to be the same for hepatitis C virus (HCV)-monoinfected patients (HCV-Mono) and HIV/HCV-coinfected patients (HCV-Co). However, the high sustained viral response (SVR) rates of DAA regimens and the small number of HIV-infected patients included in registration trials have made it difficult to identify predictors of treatment failure, including the presence of HIV. METHODS: We compared treatment outcomes for ledipasvir/sofosbuvir (LDV/SOF) against HCV G1 in treatment-naïve HCV-Mono and HCV-Co without cirrhosis in a prospective registry of individuals receiving DAAs for HCV. RESULTS: Up to September 2017, a total of 17 269 patients were registered, and 1358 patients (1055 HCV-Mono/303 HCV-Co) met the inclusion criteria. Significant differences between HCV-Mono and HCV-Co were observed for age, gender, and G1 subtype distribution. Among HCV-Co, 99.0% were receiving antiretroviral therapy. SVR rates for LDV/SOF at 8 weeks did not differ significantly between HCV-Mono and HCV-Co (96.9% vs 94.0%; P = .199). However, the SVR rate for LDV/SOF at 12 weeks was significantly higher for HCV-Mono than HCV-Co (97.2% vs 91.8%; P = .001). A multivariable logistic regression model including age, sex, liver stiffness, G1 subtype, HCV-RNA, HIV, and treatment duration showed the factors associated with treatment failure to be male sex (adjusted odds ratio [aOR], 2.49; 95% confidence interval [CI], 1.27-4.91; P = .008) and HIV infection (aOR, 2.23; 95% CI, 1.13-4.38; P = .020). CONCLUSIONS: The results of this large prospective study analyzing outcomes for LDV/SOF against HCV G1 in treatment-naïve noncirrhotic patients suggest that HIV infection is a predictor of treatment failure in patients with chronic hepatitis C.

RESUMEN

The use of extracorporeal membrane oxygenation (ECMO) in patients who have acute respiratory distress syndrome has been generally beneficial. However, because of various concerns, ECMO has rarely been used in patients who have human immunodeficiency virus infection with or without acquired immune deficiency syndrome. We report our successful use of venovenous ECMO in a 29-year-old man who presented with severe respiratory distress secondary to Pneumocystis jirovecii pneumonia associated with undiagnosed infection with the human immunodeficiency virus and acquired immune deficiency syndrome. After highly active antiretroviral therapy was begun, acute immune reconstitution inflammatory syndrome developed. The patient's respiratory condition deteriorated rapidly; he was placed on venovenous ECMO for 19 days and remained intubated thereafter. After a 65-day hospital stay and inpatient pulmonary rehabilitation, he recovered fully. In addition to presenting this case, we review the few previous reports and note the multidisciplinary medical and surgical support necessary to treat similar patients.

Asunto(s)

Síndrome de Inmunodeficiencia Adquirida/complicaciones , Oxigenación por Membrana Extracorpórea/métodos , VIH , Pneumocystis carinii/aislamiento & purificación , Neumonía por Pneumocystis/complicaciones , Insuficiencia Respiratoria/terapia , Síndrome de Inmunodeficiencia Adquirida/virología , Adulto , Ecocardiografía Transesofágica , Fluoroscopía , Humanos , Masculino , Neumonía por Pneumocystis/microbiología , Neumonía por Pneumocystis/terapia , Radiografía Torácica , Insuficiencia Respiratoria/etiología

RESUMEN

Neurocognitive screeners are used to detect symptoms of HIV-Associated Neurocognitive Disorders (HAND). However, the degree to which education and socioeconomic status affect these screeners remains unclear. Neurocognitive screeners were administered to 187 socioeconomically disadvantaged HIV+ individuals upon entering treatment who had no other risk factors for HAND. The false positive rates were: 84% for the Montreal Cognitive Assessment, 59% for the International HIV Dementia Scale, and 28.3% for the Modified HIV Dementia Scale. Given these high false positive rates, the screeners may be more useful for establishing baseline functioning and sequential testing to detect deterioration.

Asunto(s)

Complejo SIDA Demencia/diagnóstico , Pruebas Neuropsicológicas/normas , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pobreza , Poblaciones Vulnerables , Adulto Joven

RESUMEN

BACKGROUND: The Xpert™ MTB/RIF (XP) has a higher sensitivity than sputum smear microscopy (70% versus 35%) for TB diagnosis and has been endorsed by the WHO for TB high burden countries to increase case finding among HIV co-infected presumptive TB patients. Its impact on the diagnosis of smear-negative TB in a routine care setting is unclear. We determined the change in diagnosis, treatment and mortality of smear-negative presumptive TB with routine use of Xpert MTB/RIF (XP). METHODS: Prospective cohort study of HIV-positive smear-negative presumptive TB patients during a 12-month period after XP implementation in a well-staffed and trained integrated TB/HIV clinic in Kampala, Uganda. Prior to testing clinicians were asked to decide whether they would treat empirically prior to Xpert result; actual treatment was decided upon receipt of the XP result. We compared empirical and XP-informed treatment decisions and all-cause mortality in the first year. RESULTS: Of 411 smear-negative presumptive TB patients, 175 (43%) received an XP; their baseline characteristics did not differ. XP positivity was similar in patients with a pre-XP empirical diagnosis and those without (9/29 [17%] versus 14/142 [10%], P = 0.23). Despite XP testing high levels of empirical treatment prevailed (18%), although XP results did change who ultimately was treated for TB. When adjusted for CD4 count, empirical treatment was not associated with higher mortality compared to no or microbiologically confirmed treatment. CONCLUSIONS: XP usage was lower than expected. The lower sensitivity of XP in smear-negative HIV-positive patients led experienced clinicians to use XP as a "rule-in" rather than "rule-out" test, with the majority of patients still treated empirically.

Asunto(s)

Técnicas de Diagnóstico Molecular/métodos , Tuberculosis/diagnóstico , Tuberculosis/mortalidad , Adulto , Recuento de Linfocito CD4 , Estudios de Cohortes , Coinfección/tratamiento farmacológico , Coinfección/mortalidad , Femenino , Infecciones por VIH/complicaciones , Humanos , Masculino , Microscopía , Mycobacterium tuberculosis/genética , Estudios Prospectivos , Sensibilidad y Especificidad , Esputo/microbiología , Tuberculosis/tratamiento farmacológico , Tuberculosis/virología , Uganda/epidemiología

RESUMEN

The study of the etiological agents of community-acquired pulmonary infections is important to guide empirical therapy, requires constant updating, and has a substantial impact on the prognosis of patients. The objective of this study is to determine prospectively the etiology of community-acquired pulmonary infections in hospitalized adults living with HIV. Patients were submitted to an extended microbiological investigation that included molecular methods. The microbiological findings were evaluated according to severity of the disease and pneumococcal vaccine status. Two hundred twenty-four patients underwent the extended microbiological investigation of whom 143 (64%) had an etiology determined. Among the 143 patients with a determined etiology, Pneumocystis jirovecii was the main agent, detected in 52 (36%) cases and followed by Mycobacterium tuberculosis accounting for 28 (20%) cases. Streptococcus pneumoniae and Rhinovirus were diagnosed in 22 (15%) cases each and influenza in 15 (10%) cases. Among atypical bacteria, Mycoplasma pneumoniae was responsible for 12 (8%) and Chlamydophila pneumoniae for 7 (5%) cases. Mixed infections occurred in 48 cases (34%). S pneumoniae was associated with higher severity scores and not associated with vaccine status. By using extended diagnostics, a microbiological agent could be determined in the majority of patients living with HIV affected by community-acquired pulmonary infections. Our findings can guide clinicians in the choice of empirical therapy for hospitalized pulmonary disease

Asunto(s)

Humanos , VIH , Infecciones Comunitarias Adquiridas/etiología , Enfermedades Pulmonares/microbiología

RESUMEN

Over the last 2 decades human immunodeficiency virus (HIV) infection has become a chronic disease requiring long-term management. Aging, antiretroviral therapy, chronic inflammation, and several other factors contribute to the increased risk of cardiovascular disease in patients infected with HIV. In low-income and middle-income countries where antiretroviral therapy access is limited, cardiac disease is most commonly related to opportunistic infections and end-stage manifestations of HIV/acquired immunodeficiency syndrome, including HIV-associated cardiomyopathy, pericarditis, and pulmonary arterial hypertension. Cardiovascular screening, prevention, and risk factor management are important factors in the management of patients infected with HIV worldwide.

Asunto(s)

Enfermedades Cardiovasculares , Infecciones por VIH/complicaciones , VIH , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/etiología , Salud Global , Infecciones por VIH/epidemiología , Humanos , Incidencia , Factores de Riesgo

RESUMEN

Surgical intervention for severe tricuspid regurgitation secondary to remote infective endocarditis has been infrequent, especially in patients also infected with the human immunodeficiency virus (HIV). We describe the case of a 62-year-old HIV-positive man, with a 24-year history of endocarditis caused by intravenous heroin use, who presented with severe tricuspid regurgitation. The patient was initially asymptomatic, was taking antiretroviral medications, and had a satisfactory CD4 count and an undetectable viral load, so we decided to manage the regurgitation conservatively. Two years later, he presented with biventricular heart failure and dyspnea. After surgical tricuspid valve replacement, his condition improved substantially. This case illustrates that HIV-infected patients with complex medical conditions can successfully undergo cardiac surgery.

Asunto(s)

Endocarditis/complicaciones , Infecciones por VIH/complicaciones , Implantación de Prótesis de Válvulas Cardíacas , Dependencia de Heroína/complicaciones , Abuso de Sustancias por Vía Intravenosa/complicaciones , Insuficiencia de la Válvula Tricúspide/cirugía , Fármacos Anti-VIH/uso terapéutico , Recuento de Linfocito CD4 , Progresión de la Enfermedad , Disnea/etiología , Ecocardiografía Doppler en Color , Endocarditis/diagnóstico , Infecciones por VIH/diagnóstico , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/inmunología , Insuficiencia Cardíaca/etiología , Humanos , Masculino , Persona de Mediana Edad , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Insuficiencia de la Válvula Tricúspide/diagnóstico , Insuficiencia de la Válvula Tricúspide/etiología , Carga Viral

RESUMEN

BACKGROUND: In the pre-antiretroviral therapy (ART) era, markers of increased disease severity during an acute opportunistic infection (OI) were associated with mortality. Even with ART, mortality remains high during the first year after an OI in persons with advanced HIV infection, but it is unclear whether previous predictors of mortality remain valid in the current era. OBJECTIVE: To determine clinical and immunological predictors of death after an OI. METHODS: We used clinical data and stored plasma from ACTG A5164, a multicenter study evaluating the optimal timing of ART during a nontuberculous OI. We developed Cox models evaluating associations between clinical parameters and plasma marker levels at entry and time to death over the first 48 weeks after the diagnosis of OI. We developed multivariable models incorporating only clinical parameters, only plasma marker levels, or both. RESULTS: The median CD4+ T-cell count in study participants at baseline was 29 cells/µL. Sixty-four percent of subjects had Pneumocystis jirovecii pneumonia (PCP). Twenty-three of 282 (8.2%) subjects died. In univariate analyses, entry mycobacterial infection, OI number, hospitalization, low albumin, low hemoglobin, lower CD4, and higher IL-8 and sTNFrII levels and lower IL-17 levels were associated with mortality. In the combined model using both clinical and immunologic parameters, the presence of an entry mycobacterial infection and higher sTNFrII levels were significantly associated with death. CONCLUSIONS: In the ART era, clinical risk factors for death previously identified in the pre-ART era remain predictive. Additionally, activation of the innate immune system is associated with an increased risk of death following an acute OI.

Asunto(s)

Infecciones Oportunistas Relacionadas con el SIDA/mortalidad , Síndrome de Inmunodeficiencia Adquirida/complicaciones , Síndrome de Inmunodeficiencia Adquirida/mortalidad , Adulto , Femenino , Humanos , Masculino , Análisis Multivariante , Modelos de Riesgos Proporcionales , Factores de Riesgo

RESUMEN

The human immunodeficiency virus (HIV) can cause diverse cardiovascular complications. In HIV patients on antiretroviral therapy, the prevalence of myocardial infarction has steadily increased over the years. Young patients who are naïve to antiretroviral therapy and who experience coronary events are not well represented in the medical literature. We describe the case of a 22-year-old man, infected with HIV for 4 years and never treated with antiretroviral therapy, who emergently presented with a non-ST-segment-elevation myocardial infarction. Coronary angiograms revealed thrombosis and multiple coronary artery aneurysms; however, no areas of atherosclerotic stenosis were apparent. He was successfully treated with coronary stenting, antiplatelet therapy, and anticoagulation. Nine months after the initial presentation, he exhibited excellent exercise capacity, and no ischemia was evident. We discuss the various therapeutic approaches in this case.

Asunto(s)

Angioplastia Coronaria con Balón , Aspirina/administración & dosificación , Aneurisma Coronario , Trombosis Coronaria , Infecciones por VIH/complicaciones , Stents , Ticlopidina/análogos & derivados , Angioplastia Coronaria con Balón/instrumentación , Angioplastia Coronaria con Balón/métodos , Anticoagulantes/administración & dosificación , Clopidogrel , Aneurisma Coronario/diagnóstico , Aneurisma Coronario/etiología , Aneurisma Coronario/fisiopatología , Angiografía Coronaria/métodos , Trombosis Coronaria/diagnóstico , Trombosis Coronaria/etiología , Trombosis Coronaria/fisiopatología , Electrocardiografía , VIH/patogenicidad , Infecciones por VIH/virología , Humanos , Masculino , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/etiología , Infarto del Miocardio/fisiopatología , Infarto del Miocardio/terapia , Inhibidores de Agregación Plaquetaria/administración & dosificación , Ticlopidina/administración & dosificación , Resultado del Tratamiento , Adulto Joven

RESUMEN

Patients with lymphoma can develop cardiac involvement that includes malignant pericardial effusions and myocardial infiltration, but extensive myocardial invasion by tumor with resultant rupture has been reported only rarely. We report a case of a patient with human immunodeficiency virus and T-cell lymphoma who presented with signs and symptoms that were suggestive of a non-ST-elevation myocardial infarction. Plans were made for cardiac catheterization, but the patient developed thrombocytopenia after the initiation of heparin and eptifibatide. Cardiac catheterization was deferred, and shortly afterwards he had a witnessed cardiac arrest in the hospital and could not be resuscitated. Autopsy revealed transmural infiltration of the myocardium with lymphoma and resultant rupture of the left ventricular free wall. To our knowledge, this is the 1st reported case of left ventricular free-wall rupture due to transmural infiltration by human-immunodeficiency-virus-associated peripheral T-cell lymphoma.We conclude that noncoronary causes of chest pain, including direct myocardial infiltration, should be considered in immunocompromised patients with lymphoma.

Asunto(s)

Rotura Cardíaca/etiología , Ventrículos Cardíacos/patología , Linfoma Relacionado con SIDA/complicaciones , Linfoma de Células T/complicaciones , Autopsia , Dolor en el Pecho/etiología , Resultado Fatal , Paro Cardíaco/etiología , Rotura Cardíaca/patología , Humanos , Linfoma Relacionado con SIDA/patología , Linfoma de Células T/patología , Masculino , Persona de Mediana Edad , Invasividad Neoplásica

RESUMEN

How does a Pacific country deal with someone who is HIV positive? What support can be expected from society and family if one is infected by HIV? How does the rhetoric of being a family-oriented and caring society fit with the realities of what happens to HIV positive people? This presentation talks about the experience of an HIV positive woman. Peati Maiava is from Samoa. She was married in June 1992 and subsequently had two sons. Her youngest son, Fiti, died after much suffering of an undiagnosed disease in January 1996. Her husband died, after being diagnosed with AIDS in April 1996. Before he died, he pleaded for forgiveness for the chaos he had brought to the family. Looking back, Peati strongly suspects that Fiti also died from an AIDS-related condition--although there was no medical confirmation at the time. Before he died, Peati's husband was plagued with influenza, diarrhea, fevers, boils on his face, throat, and body, immense pain and headaches, violent temper, and incredible loss of body weight. This man was once one of MANU Samoa's best flankers (footballers) ever. He died a skeleton in the wake of AIDS. In the aftermath of the two untimely deaths in the family, living with her only remaining son Natal was unbearable; Peati knew she was HIV-positive and that it was only a matter of time before she would face a similar death. Her life became intolerable--after the death of her husband she was forced from her employment when her employer learned of her positive status. Some of her so-called friends and relatives also turned their back on her. With no employment and HIV-positive status she considered suicide. But her love of God and the love of her son she could not forsake. Peati did forgive her husband before he died but the scars and bitter memories are hard to overcome at times. Peati thanked the conference for the sponsorship, which allowed her to attend the conference. The moral and financial support offered to by her friends, and to Andrew Peteru who was instrumental in helping her to participate in the conference.

Asunto(s)

Síndrome de Inmunodeficiencia Adquirida , Infecciones por VIH , Prejuicio , Psicología , Conducta , Países en Desarrollo , Enfermedad , Islas del Pacífico , Polinesia , Samoa , Problemas Sociales , Virosis

RESUMEN

This study examines the relationships among health-related quality of life (HRQL), social support, sociodemographic factors and disease-related factors in persons infected with the human immunodeficiency virus (HIV) living in Venezuela. A sample of 118 HIV-infected persons living in Caracas, Venezuela, was surveyed using a written questionnaire that included a Spanish translation of the Interpersonal Support Evaluation List (ISEL) developed for this study, the Medical Outcomes Study Short Form-36 (SF-36) and a symptom inventory. All three instruments showed good internal consistency reliability. Multiple regression analyses were used to model SF-36 sub-scale scores as a function of symptoms, social support, HIV-status and use of antiretroviral drugs. The models explained between 16 and 39% of the variance in the different HRQL domains. Controlling for other variables in the model, level of symptomatology was significantly associated with all HRQL domains except social functioning and role-emotional scores. Social support was significantly associated with all HRQL domains except physical functioning and bodily pain. The use of antiretroviral drugs was significantly associated with social functioning. The study indicates the importance of social support to the quality of life of HIV-infected individuals in this culture.

Asunto(s)

Infecciones por VIH/psicología , Calidad de Vida , Apoyo Social , Adulto , Factores de Edad , Anciano , Análisis de Varianza , Estudios Transversales , Femenino , Infecciones por VIH/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Análisis de Regresión , Reproducibilidad de los Resultados , Factores Socioeconómicos , Encuestas y Cuestionarios , Venezuela/epidemiología

RESUMEN

More than 18 million persons in the world are estimated to have been infected with human immunodeficiency virus (HIV), the cause of the acquired immunodeficiency syndrome (AIDS). As immunodeficiency progresses, these persons become susceptible to a wide variety of opportunistic infections (OIs) The spectrum of OIs varies among regions of the world. Tuberculosis is the most common serious OI in sub-Saharan Africa and is also more common in Latin America and in Asia than in the United States. Bacterial and parasitic infections are prevalent in Africa; protozoal infections such as toxoplasmosis, cryptosporidiosis, and isosporiasis are also common in Latin America. Fungal infections, including cryptococcosis and Penicillium marneffei infection, appear to be prevalent in Southeast Asia. Despite limited health resources in these regions, some measures that are recommended to prevent OIs in the United States may be useful for prolonging and improving the quality of life of HIV-infected persons. These include trimethoprim-sulfamethoxazole to prevent Pneumocystis carinii pneumonia, toxoplasmosis, and bacterial infections; isoniazid to prevent tuberculosis; and 23-valent pneumococcal vaccine to prevent disease due to Streptococcus pneumoniae. Research is needed to determine the spectrum of OIs and the efficacy of various prevention measures in resource-poor nations, and health officials need to determine a minimum standard of care for HIV-infected persons. An increasing problem in the developing world, HIV/AIDS should receive attention comparable to other tropical diseases.

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PIP: Worldwide, there are more than 18 million persons infected with HIV, the cause of AIDS. As HIV disease progresses, HIV-infected persons become vulnerable to various opportunistic infections that tend to vary from region to region. Tuberculosis is the most frequent serious opportunistic infection in sub-Saharan Africa. It is more prevalent in Latin America and in Asia than in the US. Bacterial and parasitic infections are common in sub-Saharan Africa. Toxoplasmosis, cryptosporidiosis, isosporiasis, and other fungal diseases are prevalent in Latin America. Fungal diseases, particularly cryptococcoses, and Penicillium marneffei infection, seem to also be prevalent in Asia. These regions have limited health resources. Regimens designed to prevent opportunistic infections that prolong and improve the quality of life of HIV-infected persons include trimethoprim-sulfamethoxazole to prevent Pneumocystis carinii pneumonia, toxoplasmosis, and bacterial infections; isoniazid to prevent tuberculosis; and 23-valent pneumococcal vaccine to Streptococcus pneumonia pneumonia. Scientists need to conduct research to identify the spectrum of opportunistic infections and the efficacy of different prevention measures in resource-poor countries. Health officials need to develop a minimum standard of care for HIV-infected patients. Since HIV/AIDS continues to grow in developing countries, scientists and health providers should pay as much attention to HIV/AIDS as to other tropical diseases.

Asunto(s)

Infecciones Oportunistas Relacionadas con el SIDA/prevención & control , Países en Desarrollo , Infecciones Oportunistas Relacionadas con el SIDA/epidemiología , África/epidemiología , Antiinfecciosos/uso terapéutico , Antituberculosos/uso terapéutico , Asia/epidemiología , Vacunas Bacterianas/uso terapéutico , Región del Caribe/epidemiología , Quimioterapia Combinada , Humanos , Isoniazida/uso terapéutico , América Latina/epidemiología , Vacunas Neumococicas , Investigación , Sulfametoxazol/uso terapéutico , Trimetoprim/uso terapéutico

RESUMEN

To determine the types of pulmonary disease associated with human immunodeficiency virus (HIV) infection, we conducted a prospective study of 302 consecutive patients admitted for acute respiratory disease to a university hospital in Bujumbura, Burundi. Diagnoses were made according to well-defined criteria. Of the total, 222 patients (73.5%) were HIV seropositive, with women younger than men. Features suggestive of underlying HIV infection were the clinical findings of oral thrush, peripheral lymphadenopathy, or herpes zoster and the radiographic abnormalities of hilar-mediastinal adenopathy or a reticulonodular infiltrate. Tuberculosis and community-acquired pneumonia occurred with approximately equal frequency in the HIV-seropositive and seronegative groups. Pneumocystis carinii pneumonia was diagnosed in 11 patients, all seropositive. Gram-negative bacteremia, especially Salmonella typhimurium, occurred in 23 seropositive patients (10.4%). A total of 24 seropositive patients died during the initial hospitalization, and 11 others required readmission; no seronegative patients died or were rehospitalized. We conclude that HIV infection is a major risk factor for the development of acute respiratory diseases in adults of sufficient severity to require hospitalization in Bujumbura. In this Central African country, where exposure to virulent bacterial pathogens is ubiquitous, tuberculosis, pneumonia, and salmonellosis occur with much greater frequency than classic AIDS-defining opportunistic infections or malignancies.

Asunto(s)

Infecciones Oportunistas Relacionadas con el SIDA/complicaciones , VIH-1 , Infecciones del Sistema Respiratorio/etiología , Infecciones Oportunistas Relacionadas con el SIDA/diagnóstico , Infecciones Oportunistas Relacionadas con el SIDA/epidemiología , Enfermedad Aguda , Adolescente , Adulto , Burundi/epidemiología , Femenino , Seropositividad para VIH/complicaciones , Seropositividad para VIH/diagnóstico , Seroprevalencia de VIH , Hospitalización/estadística & datos numéricos , Humanos , Pulmón/diagnóstico por imagen , Masculino , Prevalencia , Estudios Prospectivos , Radiografía , Infecciones del Sistema Respiratorio/diagnóstico , Infecciones del Sistema Respiratorio/epidemiología , Prueba de Tuberculina , Tuberculosis Pulmonar/diagnóstico , Tuberculosis Pulmonar/epidemiología , Tuberculosis Pulmonar/etiología

RESUMEN

PIP: HIV destroys the immune system, causing group of clinical signs which are referred to as AIDS. Some of these signs are cutaneous in nature. An acute rash on the trunk is associated with HIV seroconversion. It usually disappears in 8 days but can last for several hours or 30 days. Infectious manifestations of HIV infection are common. Candidiasis represents 90% of mycoses. It usually manifests on the tongue but can also occur on oral or genital mucosa. Antifungal medication usually treats it effectively. Yeastlike fungi cause seborrheic dermatitis, which is characterized by profuse inflammatory lesions resembling psoriasis. Topical and general antifungal medication do not effectively treat it. Dermacorticoids are more likely to be successful. Dermaphyte infections also occur HIV-infected persons. Organisms responsible for cutaneous profound mycoses, which tend to be rare but fatal, include Cryptococcus neoformans, Histoplasma capsulatum, sporotrichoses, scopulariopsis, and Pneumocystis carinii. Amphotericin B is the treatment of choice for manifestation of the first 2 organisms. Cutaneous viral infections in HIV-infected persons are caused by herpes simplex virus, herpes zoster, cytomegalovirus, Epstein Barr virus, Pox virus, and human papilloma virus. A patient who has had chronic cutaneous or mucosal herpes simplex infection for more than 1 month should be suspected of having HIV infection. Actclovir can treat herpes simplex infection, herpes zoster infection, and Epstein Barr virus (to make lesions disappear). Cytomegalovirus lesions are not specific. Cytomegalovirus infection is generally fatal. Cutaneous bacteria infections include banal infections (e.g., acne and folliculitis), syphilitic chancre lesions, and granulomatous tuberculosis. Protozoans and arthropods also cause cutaneous conditions in HIV-infected patients. Cutaneous neoplasms include Kaposi's sarcoma and other tumors (e.g., lymphomas). Other dermatoses are rare but may include psoriasis and toxidermia.^ieng

Asunto(s)

Síndrome de Inmunodeficiencia Adquirida/complicaciones , Enfermedades de la Piel/etiología , Humanos , Enfermedades de la Piel/clasificación , Enfermedades de la Piel/diagnóstico , Enfermedades de la Piel/terapia