Emergencies in HIV medicine--part I.

Human immunodeficiency virus (HIV) infection is now a chronic manageable disease due to which is it imperative for reviewing various medical emergencies which an individual case may encounter. Emergencies may occur at any stage of the disease. HIV infection is associated with several opportunistic infections/malignancies that may be life threatening and need quick intervention by health care workers. These emergencies could be related to opportunistic infections that are seen at presentation or that occur as the immune system gets weaker, or may be HIV induced diseases like enteropathy and wasting, diarrhea leading to dehydration and its sequel, neurological complication like PML etc. and from complications resulting from use of anti-HIV medication like lactic acidosis, pancreatitis, bone marrow suppression and may include the immune reconstitution syndromes.

Feasibility of implementing an integrated tool for improvement of treatment quality and early-warning indicators for HIV drug resistance: a pilot study of centres in India.

With the rapid scale-up in use of antiretroviral therapy (ART), monitoring the quality of care and factors that may lead to emergence of HIV drug resistance (HIVDR) is an important focus point for programme managers. The National AIDS Control Organisation of India embarked on strengthening the ART programme for continuous quality improvement (CQI), using defined quality-of-care indicators (QCIs), including World Health Organization (WHO) early-warning indicators (EWIs) for HIVDR. In this feasibility study, done during July 2014, an integrated QCI and EWI tool developed by WHO India was pilot tested across 18 purposively selected ART centres. At seven ART centres, the EWI 1 target of >90% on-time pill pick-up was achieved for adult patients, while among the paediatric age group (<15 years old) it was not achieved by any centre. EWI 2 (retention of patients in ART care at 12 months after initiation) showed that two centres had retention of both adult and paediatric patients of >85% at 12 months of ART, while 11 centres had retention between 75% and 85%. EWI 3 (pharmacy stock-out) for adult and paediatric patients showed that 11 ART centres reported a minimum of one stock-out for the first-line ART drugs in the reporting period, while EWI 4 targets (pharmacy dispensing practices) were achieved by all the centres, for both adults and children. Average retention in care at 6, 12 and 24 months after ART initiation was 82%, 77% and 71%, respectively. This feasibility study showed that EWI analyses were much simpler to conduct if information was sought only for patients receiving ART, for whom the quality of record-keeping is better and more consistent. The activity has highlighted the need for improved quality of record-keeping at the facilities and implementation of specific interventions to ensure better patient follow-up. After modifications, use of the tool will be phased in across all the ART centres in India.

Colo-colic intussusception due to intestinal lipomatosis.

Lipomas of the small intestine are usually found incidentally; symptoms occur in less than one-third of affected patients, especially when lipomas are more than 2 cm in size. We report a 32-year-old man in whom intestinal lipomatosis resulted in colo-colic intussusception. These symptoms disappeared following operative resection of about 60 cm of ileum and ascending colon.

A clinical scoring system as useful as FNAC in the diagnosis of tuberculous lymphadenitis in HIV positive patients.

Among HIV positive patients, Fine needle aspiration cytology (FNAC) or biopsy for diagnosis of tuberculous lymphadenopathy is often avoided due to an unspoken stigma. Earlier, we had developed a clinical scoring scale for the diagnosis of tuberculous lymphadenitis (TBLN), which had 88% sensitivity and detected no false positives. In the present study, we attempted to develop similar scale that could assist in diagnosing TBLN in AIDS. All 42 HIV positive patients of adenitis attending Ramdeo Hospital and Research Centre, Jodhpur between August 2001 and December 2004 were studied. History of past tuberculosis, age, history of rapid weight loss, site, size, consistency, and the presence of matting and sinus formation of enlarged lymph nodes, result of tuberculin test, sputum smear and findings in chest radiograph were compared between patients diagnosed as TBLN and those showing non-tuberculous lymphadenitis (Non-TBLN) on cytopathological examination of material obtained by fine needle aspiration. Based on the results, clinical scores from zero to two were assigned to different clinical features. The total clinical score was then calculated for each patient. A total clinical score of five or more included all TBLN cases and only 10.5% false positives. This scoring system can be used in remote peripheral areas, which do not have the facility for biopsy or FNAC.