Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer.

BACKGROUND: The incidence of anal cancer is substantially higher among persons living with the human immunodeficiency virus (HIV) than in the general population. Similar to cervical cancer, anal cancer is preceded by high-grade squamous intraepithelial lesions (HSILs). Treatment for cervical HSIL reduces progression to cervical cancer; however, data from prospective studies of treatment for anal HSIL to prevent anal cancer are lacking. METHODS: We conducted a phase 3 trial at 25 U.S. sites. Persons living with HIV who were 35 years of age or older and who had biopsy-proven anal HSIL were randomly assigned, in a 1:1 ratio, to receive either HSIL treatment or active monitoring without treatment. Treatment included office-based ablative procedures, ablation or excision under anesthesia, or the administration of topical fluorouracil or imiquimod. The primary outcome was progression to anal cancer in a time-to-event analysis. Participants in the treatment group were treated until HSIL was completely resolved. All the participants underwent high-resolution anoscopy at least every 6 months; biopsy was also performed for suspected ongoing HSIL in the treatment group, annually in the active-monitoring group, or any time there was concern for cancer. RESULTS: Of 4459 participants who underwent randomization, 4446 (99.7%) were included in the analysis of the time to progression to cancer. With a median follow-up of 25.8 months, 9 cases were diagnosed in the treatment group (173 per 100,000 person-years; 95% confidence interval [CI], 90 to 332) and 21 cases in the active-monitoring group (402 per 100,000 person-years; 95% CI, 262 to 616). The rate of progression to anal cancer was lower in the treatment group than in the active-monitoring group by 57% (95% CI, 6 to 80; P = 0.03 by log-rank test). CONCLUSIONS: Among participants with biopsy-proven anal HSIL, the risk of anal cancer was significantly lower with treatment for anal HSIL than with active monitoring. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT02135419.).

Transition From Pediatric and Adolescent HIV Care to Adult HIV Care and the Patient-Provider Relationship: A Qualitative Metasynthesis.

ABSTRACT: Approximately 5 million adolescents (ages 15-24 years) living with HIV will transition to adult care in the next decade. Only half are engaged in care 12 months post-transition. This qualitative metasynthesis aimed to answer: What effect did the patient-provider relationship (PPR) have on adolescent living with HIV transition? What strategies were suggested to develop trusting relationships to promote engagement and retention in care? Primary qualitative studies from PubMed, CINAHL, and EBSCO (January 2008 to December 2019) were identified. Data were analyzed using team-based thematic synthesis techniques and international standards. Fourteen articles with 478 participants from eight countries were included. Four themes emerged: the familial nature of the PPR, stigma as a bond and barrier, the provider knowing the patient and getting to know new providers, and recommendations supporting transition. The PPR is integral. Collaborative strategies used to build new relationships will support autonomy, decrease stigma, and facilitate trust.

Endocarditis Caused by Candida parapsilosis Presenting With Severe Thrombocytopenia in a Patient With Tetralogy of Fallot.

Infective endocarditis (IE) occurs more frequently in individuals living with congenital heart disease, often with high morbidity and mortality. Although gram-positive bacterial infections commonly cause IE, prosthetic valves are a known risk factor for fungal IE. We report a case of prosthetic pulmonary valve Candida parapsilosis IE in a 58-year-old male with repaired tetralogy of Fallot. He presented with fatigue, petechiae, and hematochezia. He had severe thrombocytopenia from idiopathic/immune thrombocytopenia purpura, which resolved with steroids and immunoglobulin. Treatment with antifungals as well as a surgical pulmonary valve replacement resulted in recovery without relapse at greater than a year.

A basic needs assessment of Kenyan health care practitioners' training and ability in providing resuscitation management for patients in Mbagathi Hospital, Nairobi.

STUDY OBJECTIVE: To determine if health care providers at one district hospital in Nairobi, Kenya, possess the training and confidence necessary to attend to basic needs for patient resuscitation. DESIGN: Prospective cohort study. SETTING: Mbagathi District Hospital, Nairobi, Kenya, a 300-bed, government district-level health care facility serving over one million Kenyans. SUBJECTS: 21 medical officers, clinical officers, medical officer and clinical officer interns, and nurses. MEASUREMENTS: An investigator-designed survey, the Self Assessment of Clinical Skills, designed to assess training and level of confidence in addressing basic resuscitation, was administered. MAIN RESULTS: 80% of respondents have been taught how to maintain a patent airway, but 22% felt less than confident in their ability. Nearly two thirds (62%) of respondents had not been trained to use a pulse oximeter. 100% of respondents felt they would benefit from additional training in airway and pulse oximetry assessment. While 90% reported that they had been taught to treat hypotension and 76% had experience treating hypotension, only 62% felt confident in their ability to treat hypotension. 95% desired additional training in hypotension management. 85% wanted additional training in measuring blood pressure, and every respondent desired additional training in the other circulatory monitoring skills listed on the survey. CONCLUSIONS: Providers of the Mbagathi District Hospital, Nairobi, report a lack of confidence in recognizing basic resuscitation needs, and they desire additional training.