[Intralesional Injections of 5-Fluorouracil: innovative and effective treatment of Primary Pterygium]. / Inyecciones Intralesionales de 5-Fluorouracilo: tratamiento innovador y efectivo de Pterigión Primario.

OBJECTIVES: To determine the effectiveness of intralesional 5-Fluorouracil (5-FU) in symptomatic relief, astigmatism, and desire for surgery in patients with primary pterygium. METHODS: The experimental study was carried out between January and March 2020 in the Ophthalmology Unit of the Hospital del Salvador, Chile. Fourteen eyes (14 patients) were selected on the surgical waiting list and exposed to fortnightly intralesional injections of 10 mg of 5-FU. An initial evaluation was performed with OSDI for symptomatic measurement, a photographic camera and slit lamp for clinical appearance, and an auto-refractometer for astigmatism, being re-evaluated 60 days later, adding the question of whether they maintained the desire to undergo surgery. The sample was divided into groups A and B depending on whether they received two or one dose of 5-FU, respectively. RESULTS: The average age of the participants was 56.8 ± 11.1 years. Group A presented an initial OSDI of 50 ± 23.8, which, after the intervention, decreased to 21 ± 13.5 (p < 0.001). Group B had an initial OSDI of 47 ± 17.3, decreasing to 22 ± 16.2 (p < 0.005)-statistically significant changes. The degree of astigmatism had no changes. Regarding the physical aspect, there was a reduction in the size of the lesion in 2 of the 14 patients, both in group A. Two patients decided not to undergo surgery after the intervention. CONCLUSIONS: The intralesional injection of 5-FU showed a significant improvement in symptomatic relief without associated complications, generating a therapeutic alternative in patients with primary pterygium without surgical indication.

Pharmacogenetics-Based Preliminary Algorithm to Predict the Incidence of Infection in Patients Receiving Cytotoxic Chemotherapy for Hematological Malignancies: A Discovery Cohort.

Introduction: Infections in hematological cancer patients are common and usually life-threatening; avoiding them could decrease morbidity, mortality, and cost. Genes associated with antineoplastics' pharmacokinetics or with the immune/inflammatory response could explain variability in infection occurrence. Objective: To build a pharmacogenetic-based algorithm to predict the incidence of infections in patients undergoing cytotoxic chemotherapy. Methods: Prospective cohort study in adult patients receiving cytotoxic chemotherapy to treat leukemia, lymphoma, or myeloma in two hospitals in Santiago, Chile. We constructed the predictive model using logistic regression. We assessed thirteen genetic polymorphisms (including nine pharmacokinetic-related genes and four inflammatory response-related genes) and sociodemographic/clinical variables to be incorporated into the model. The model's calibration and discrimination were used to compare models; they were assessed by the Hosmer-Lemeshow goodness-of-fit test and area under the ROC curve, respectively, in association with Pseudo-R2. Results: We analyzed 203 chemotherapy cycles in 50 patients (47.8 ± 16.1 years; 56% women), including 13 (26%) with acute lymphoblastic and 12 (24%) with myeloblastic leukemia. Pharmacokinetics-related polymorphisms incorporated into the model were CYP3A4 rs2242480C>T and OAT4 rs11231809T>A. Immune/inflammatory response-related polymorphisms were TLR2 rs4696480T>A and IL-6 rs1800796C>G. Clinical/demographic variables incorporated into the model were chemotherapy type and cycle, diagnosis, days in neutropenia, age, and sex. The Pseudo-R2 was 0.56, the p-value of the Hosmer-Lemeshow test was 0.98, showing good goodness-of-fit, and the area under the ROC curve was 0.93, showing good diagnostic accuracy. Conclusions: Genetics can help to predict infections in patients undergoing chemotherapy. This algorithm should be validated and could be used to save lives, decrease economic costs, and optimize limited health resources.

IL-6 -572C>G and CARD8 304T>A Genetic Polymorphisms are Associated with the Absolute Neutrophil Count in Patients with Hematological Malignancies Under Chemotherapy: An Application of Multilevel Models to a Preliminary Pharmacogenetic Study.

PURPOSE: Neutropenia is a common event in patients undergoing cytotoxic chemotherapy for the treatment of a hematological malignancy. Some polymorphisms, as IL-6 -572C>G (rs1800796), IL-1ß -31 G>A (rs1143627), and CARD8 304T>A (rs2043211), in genes related to the inflammatory process, could affect the level of absolute neutrophil count (ANC) after chemotherapy. Since an efficient inflammatory process enhances neutrophil survival, we hypothesize that these polymorphisms are associated with ANC. PATIENTS AND METHODS: We carried out a prospective cohort study in two hospitals in Santiago, Chile. The patients included were adults diagnosed with acute myeloblastic leukemia, acute lymphoblastic leukemia, or non-Hodgkin's lymphoma, undergoing cytotoxic chemotherapy. We use a multilevel linear regression model to test our hypothesis. The best model was selected using the Akaike's information criterion (AIC). RESULTS: We analyzed 1726 hemograms and ANCs from 172 hospitalizations from 32 patients. The results show that CC and CG genotypes of IL-6 -572 C>G polymorphism are associated with higher ANCs compared with the GG genotype (Ln (ANC) ~ 0.81 IC95% 0.02-1.55). Similarly, TT and AT genotypes of CARD8 304T>A polymorphism were related to higher ANCs compared with AA (Ln (ANC) ~ 0.95 IC95% 0.02-1.82). IL-1ß genetic polymorphism had no statistically significant association with ANC. CONCLUSION: IL-6 rs1800796 -572C>G and CARD8 rs2043211 304T>A polymorphisms are associated with the absolute neutrophil count in patients undergoing cytotoxic chemotherapy for treatment of hematological malignancies. Our findings might be useful to improve the safety of chemotherapy through predictive ANC models.

Extending access to care across the rural US south: Preliminary results from the Alabama eHealth programme.

PURPOSE: Using a mixed-methods formative evaluation, the purpose of this study was to provide a broad overview of the Alabama eHealth programme set-up and initial patient outcomes. The Alabama eHealth programme uses telemedicine to provide medical care to people living with HIV in rural Alabama. It was led by a community-based organisation, Medical Advocacy and Outreach (MAO), and supported by AIDS United and the Corporation for National Community Service's Social Innovation Fund with matching support from non-federal donors. METHODS: We conducted and transcribed in-depth interviews with Alabama eHealth staff and then performed directed content analysis. We also tracked patients' ( n = 240) appointment attendance, CD4 counts, and viral loads. FINDINGS: Staff described the steps taken to establish the programme, associated challenges (e.g., costly, inadequate broadband in rural areas), and technology enabling this programme (electronic medical records, telemedicine equipment). Of all enrolled patients, 76% were retained in care, 88% had antiretroviral therapy and 75% had a suppressed viral load. Among patients without missing data, 96% were retained in care, 97% used antiretroviral therapy and 93% had suppressed viral loads. There were no statistically significant demographic differences between those with and without missing data. CONCLUSIONS: Patients enrolled in a telemedicine programme evaluation successfully moved through the HIV continuum of care.

Inyecciones Intralesionales de 5-Fluorouracilo: tratamiento innovador y efectivo de Pterigión Primario / Intralesional Injections of 5-Fluorouracil: innovative and effective treatment of Primary Pterygium

OBJETIVO: Determinar la efectividad de 5-Fluorouracilo intralesional en el alivio sintomático, astigmatismo y deseo de cirugía en pacientes con pterigión primario. Métodos: Estudio experimental realizado entre enero y marzo de 2020 en la Unidad de Oftalmología del Hospital del Salvador, Chile. Se seleccionaron 14 ojos (14 pacientes) en lista de espera quirúrgica, expuestos a inyecciones intralesionales quincenales de 10 mg de 5-FU. Se realizó una evaluación clínica inicial con OSDI para medición sintomática, cámara fotográfica y lámpara de hendidura para apariencia clínica, y autorrefractómetro para astigmatismo, siendo reevaluados 60 días después, añadiéndose la pregunta de si mantenían el deseo de operarse. Se dividió la muestra en grupo A y B según recibieron dos o una dosis de 5-FU, respectivamente. RESULTADOS: La edad promedio de los participantes fue 56,8 ± 11,1 años. El grupo A presentó un OSDI inicial de 50 ± 23,8 que, posterior a la intervención, se redujo a 21 ± 13,5 (p < 0,001). El grupo B tuvo un OSDI inicial de 47 ± 17,3, disminuyendo a 22 ± 16,2 (p < 0,005). Ambos cambios estadísticamente significativos. En cuanto al aspecto físico, hubo reducción del tamaño lesional en 2 de los 14 pacientes, ambos del grupo A. No hubo cambios respecto al grado de astigmatismo. Hubo 2 pacientes que decidieron no realizarse la cirugía posterior a la intervención. Conclusión: La inyección intralesional de 5-FU demostró mejoría significativa en el alivio sintomático, sin complicaciones asociadas, generando un tratamiento alternativo al quirúrgico en pacientes con pterigión primario, pudiendo posponer la cirugía.

OBJETIVES: To determine the effectiveness of intralesional 5-Fluorouracil (5-FU) in symptomatic relief, astigmatism, and desire for surgery in patients with primary pterygium. Methods: The experimental study was carried out between January and March 2020 in the Ophthalmology Unit of the Hospital del Salvador, Chile. Fourteen eyes (14 patients) were selected on the surgical waiting list and exposed to fortnightly intralesional injections of 10 mg of 5-FU. An initial evaluation was performed with OSDI for symptomatic measurement, a photographic camera and slit lamp for clinical appearance, and an auto-refractometer for astigmatism, being re-evaluated 60 days later, adding the question of whether they maintained the desire to undergo surgery. The sample was divided into groups A and B depending on whether they received two or one dose of 5-FU, respectively. RESULTS: The average age of the participants was 56.8 ± 11.1 years. Group A presented an initial OSDI of 50 ± 23.8, which, after the intervention, decreased to 21 ± 13.5 (p < 0.001). Group B had an initial OSDI of 47 ± 17.3, decreasing to 22 ± 16.2 (p < 0.005)-statistically significant changes. The degree of astigmatism had no changes. Regarding the physical aspect, there was a reduction in the size of the lesion in 2 of the 14 patients, both in group A. Two patients decided not to undergo surgery after the intervention. Conclusions: The intralesional injection of 5-FU showed a significant improvement in symptomatic relief without associated complications, generating a therapeutic alternative in patients with primary pterygium without surgical indication.

The cost of care for patients with HIV from the provider economic perspective.

Health care costs for HIV infection are often reported from the economic perspective of third party payors and little data exist to show how total costs are distributed across specific health service categories. We used a retrospective cohort design to measure total medical costs for 1 year in a randomly selected sample of 280 patients treated for HIV infection at an urban health care facility. Inpatient and outpatient costs were measured from the economic perspective of the health care provider. Hospital costs included ward, ancillary, and procedure costs. Ambulatory included medications, primary and specialty care, case management, ancillary, and behavioral comorbidity treatment costs. The mean total was $20,114 per patient, of which $6,322 was for inpatient and $13,842 was for ambulatory services. Specific ambulatory costs were: medications, $9,257; primary, specialty and ancillary services, $3,470; and behavioral comorbidity treatment, $1,111. The mean annual outpatient ancillary cost was $841. Over 30% of the total service cost was for building and administrative overhead and approximately 25% of both hospital and clinic costs were for ancillary services. Independent predictors of high cost were CD4 counts, Medicaid eligibility, and behavorial comorbidities. Our outpatient costs were higher, with less variation than previously reported. Increasingly, there has been a shift of HIV care from hospital to ambulatory settings. We postulate that reimbursement rates have not captured the recent flourishing of ambulatory care. If reimbursement is not commensurate with outpatient advances, providers may be paradoxically underreimbursed for improving care.

The influence of dual-identity development on the psychosocial functioning of African-American gay and bisexual men.

To examine the influence of racial-ethnic and sexual identity development on the psychosocial functioning of African-American gay and bisexual men (AAGBM), 174 AAGBM completed questionnaire packets designed to assess their levels of racial-ethnic and sexual identity development, self-esteem, social support, male gender role stress, HIV prevention self-efficacy, psychological distress, and life satisfaction. The results indicate that AAGBM who possess more positive (i.e., integrated) self-identification as being African American and gay reported higher levels of self-esteem, HIV prevention self-efficacy, stronger social support networks, greater levels of life satisfaction, and lower levels of male gender role and psychological distress than their counterparts who reported less positive (i.e., less well integrated) African American and gay identity development. Although higher levels of racial-ethnic identity development were associated with greater levels of life satisfaction, sexual identity development was not.

Exposure to crime and trauma among HIV-infected men who have sex with men: associations with HIV stigma and treatment engagement.

Active engagement in HIV clinical care, including uptake and adherence to antiretroviral therapy (ART), is necessary to optimize treatment benefit and can reduce the spread of HIV infection. Among a predominately minority sample of 303 HIV-infected men who have sex with men (MSM) who were either newly diagnosed with HIV or showed evidence of inconsistent engagement in HIV care, we explored rates of exposure to crime, sexual and physical trauma, and associations with factors potentially related to poor engagement in care. Two thirds of participants experienced a crime-related event, and nearly one third reported exposure to physical and/or sexual trauma. All three types of exposure were related to HIV stigma and to concerns about initiating ART. Associations between exposure and social support and HIV disclosure needs were also observed. Findings have implications for the role of trauma exposure and efforts to optimize treatment engagement for HIV-infected MSM.

Pain in persons living with HIV and comorbid psychologic and substance use disorders.

OBJECTIVES: There is a dearth of information on the experience of pain in persons living with human immunodeficiency virus (HIV) and cooccurring psychologic and substance use problems. This study examined the prevalence and correlates of pain in 162 HIV-positive persons diagnosed with mood and/or anxiety disorders and substance use disorders. METHODS: Bodily pain scores in the current sample were compared with pain scores in the United States general population and HIV-positive persons who screened negative for psychologic and substance use problems. Bivariate analyses were used to identify significant correlates of pain scores in the current sample, which were then subjected to multiple regression analysis. RESULTS: Pain scores in the current sample were significantly lower (indicating more pain) than the general population and HIV-positive persons who screened negative for psychologic and substance use problems. Multivariate analysis indicated that the presence of mood disorder, older age, and lower CD4 cell counts (below 200) were associated with increased pain. Presence of mood disorder accounted for the largest amount of unique variance in pain scores. DISCUSSION: HIV-positive persons with diagnosed mood/anxiety and substance use disorders reported substantially higher levels of pain than the general population and HIV-positive persons without these comorbid conditions. The presence of mood disorder emerged as an important marker for pain in the current sample. Given that individuals living with HIV and comorbid psychologic and substance use disorders are at increased risk for pain, concerted efforts should be directed at identifying and treating pain in this population.

Substance abuse and symptoms of mental illness among HIV-positive persons in the Southeast.

OBJECTIVES: Mental illness and substance abuse have been consistently associated with poor HIV-medication adherence and other negative health outcomes. METHODS: A brief mental health and substance use screening instrument was administered to 1,362 HIV-infected individuals receiving care at two academic medical center Infectious Diseases Clinics in North Carolina. RESULTS: Study results indicated high frequencies of symptoms of mental illness (60%), substance abuse (32%), and co-occurring symptoms of mental illness and substance abuse (23%). Younger age (P = 0.03), male sex (P < 0.001), and higher viral load (P < 0.001) were associated with substance use problems. White race (P = 0.001), younger age (P = 0.023), and higher viral load (P = 0.042) were associated with symptoms of mental illness. CONCLUSIONS: In the Southeast, mental health and substance abuse services are sparse and stigma is high; thus, innovative treatment strategies are needed to address the high levels of co-occurring mental illness and substance abuse. Antiretroviral therapies will not reach their potential for slowing the HIV/AIDS epidemic and prolonging survival if comorbidities that influence patient behavior are not addressed.