Virological and Social Outcomes of HIV-Infected Adolescents and Young Adults in The Netherlands Before and After Transition to Adult Care.

BACKGROUND: As a result of effective combination antiretroviral therapy (cART) and advanced supportive healthcare, a growing number of human immunodeficiency virus (HIV)-infected children survive into adulthood. The period of transition to adult care is often associated with impaired adherence to treatment and discontinuity of care. We aimed to evaluate virological and social outcomes of HIV-infected adolescents and young adults (AYAs) before and after transition, and explore which factors are associated with virological failure. METHODS: We included 59 HIV-infected AYAs from the Netherlands who had entered into pediatric care and transitioned from pediatric to adult healthcare. We used HIV RNA load and cART data from the Dutch Stichting HIV Monitoring database (1996-2014), and collected social and treatment data from patients' medical records from all Dutch pediatric HIV treatment centers and 14 Dutch adult treatment centers involved. We evaluated risk factors for virological failure (VF) in a logistic regression model adjusted for repeated measurements. RESULTS: HIV VF occurred frequently during the study period (14%-36%). During the transition period (from 18 to 19 years of age) there was a significant increase in VF compared with the reference group of children aged 12-13 years (odds ratio, 4.26 [95% confidence interval, 1.12-16.28]; P = .03). Characteristics significantly associated with VF were low educational attainment and lack of autonomy regarding medication adherence at transition. CONCLUSIONS: HIV-infected AYAs are vulnerable to VF, especially during the transition period. Identification of HIV-infected adolescents at high risk for VF might help to improve treatment success in this group.

The Power of Flash Mob Research: Conducting a Nationwide Observational Clinical Study on Capillary Refill Time in a Single Day.

BACKGROUND: Capillary refill time (CRT) is a clinical test used to evaluate the circulatory status of patients; various methods are available to assess CRT. Conventional clinical research often demands large numbers of patients, making it costly, labor-intensive, and time-consuming. We studied the interobserver agreement on CRT in a nationwide study by using a novel method of research called flash mob research (FMR). METHODS: Physicians in the Netherlands were recruited by using word-of-mouth referrals, conventional media, and social media to participate in a nationwide, single-day, "nine-to-five," multicenter, cross-sectional, observational study to evaluate CRT. Patients aged ≥ 18 years presenting to the ED or who were hospitalized were eligible for inclusion. CRT was measured independently (by two investigators) at the patient's sternum and distal phalanx after application of pressure for 5 s (5s) and 15 s (15s). RESULTS: On October 29, 2014, a total of 458 investigators in 38 Dutch hospitals enrolled 1,734 patients. The mean CRT measured at the distal phalanx were 2.3 s (5s, SD 1.1) and 2.4 s (15s, SD 1.3). The mean CRT measured at the sternum was 2.6 s (5s, SD 1.1) and 2.7 s (15s, SD 1.1). Interobserver agreement was higher for the distal phalanx (κ value, 0.40) than for the sternum (κ value, 0.30). CONCLUSIONS: Interobserver agreement on CRT is, at best, moderate. CRT measured at the distal phalanx yielded higher interobserver agreement compared with sternal CRT measurements. FMR proved a valuable instrument to investigate a relatively simple clinical question in an inexpensive, quick, and reliable manner.

Change to abacavir-lamivudine-tenofovir combination treatment in patients with HIV-1 who had complete virological suppression.

Patients who have not received previous antiretroviral treatment (ART) have a high failure rate on the combination treatment of abacavir, lamivudine, and tenovir. We assessed the virological failure rate in eight patients with HIV-1 who switched to this combination after having complete virological suppression from their previous long-term ART (median 8.0 months, range 7.5-18.0). Five of the eight patients showed virological failure. Four of these five patients had either the K65R mutation, the M184V/I mutation, or both. This combination of drugs cannot therefore be recommended as alternative treatment in patients with HIV-1 who are fully virologically suppressed.

[Diagnostic image (109). A man with furuncles. Cutaneous myiasis]. / Diagnose in beeld (109). Een man met 'steenpuisten'. Cutane myiasis.

A 27-year-old man had 'furuncles' after a one-month stay in Gambia, which proved to be cutaneous myiasis due to Cordylobia anthropophaga.

[Subcutaneous nodules with malignant presentation, but caused by infection]. / Een subcutane zwelling met een maligne presentatie, maar met een infectieuze oorzaak.

Three patients, a woman aged 32, a boy aged 6.5 and a man aged 56 years, presented with a subcutaneous mass suggesting a malignancy: respectively a rubbery swelling, painful to the touch below the left scapula, a partly massive, partly soft swelling on the inside of the left upper leg, and a non-fluctuating mass near the right eighth rib, parasternally. Additional diagnostic investigation revealed an infectious cause: respectively Mycobacterium tuberculosis, Bartonella henselae and Salmonella typhi. Antimicrobial therapy was successful. Subcutaneous masses suspected of being a benign or malignant tumour are sometimes caused by an infection. The differential diagnosis is extensive. Sometimes the travel anamnesis yields helpful information. It is concluded that besides histopathological examination, microbiological investigation can play a major role in the evaluation of subcutaneous masses.

Isolated elevated aspartate aminotransferase: a surprising outcome for clinicians.

In this report a case of macro-aspartate aminotransferase in a 34-year-old pregnant woman is presented. Awareness of the existence of a macroenzyme is important because of their ability to cause diagnostic confusion, which leads to unnecessary investigations. Confirmation with a polyethylene glycol precipitation test is simple to perform and not expensive.

[Implementation of the curriculum for specialist training in Emergency Medicine: room for improval on details]. / Implementatie van het curriculum voor de opleiding tot Spoedeisende Hulp(SEH)-arts: zoektocht naar het verborgen curriculum.

OBJECTIVE: To investigate what aspects of the new curriculum for specialist training in Emergency Medicine are actually implemented in daily practice. DESIGN: Descriptive study. METHOD: The curriculum was implemented as a pilot in 4 teaching hospitals, where a total of 32 residents in training in Emergency Medicine and 20 Emergency Medicine Program directors and Emergency physicians were surveyed using a web-based questionnaire querying the use of the different aspects of the curriculum in daily practice. RESULTS: Responses were received from 29 residents in training and 15 program directors and Emergency physicians. Both residents in training and program directors rated the patient mix seen during the training programme adequate to excellent. No great differences were observed in how residents in training, trainers and physicians working in the Emergency Department assessed the curriculum. However, the results showed that the training plan should be discussed explicitly with each residents in training. More attention should be focussed on the Society Awareness, Knowledge and Science and Organisation competencies and the Disability and Dermatology themes. Competence-based assessment methods, such as multi-source feedback, specific to this type of curriculum have not yet been sufficiently implemented. CONCLUSION: The responses to the questionnaire demonstrated how the curriculum is handled in daily practice and provided information on the progress of the implementation of the curriculum. This will enable focussed feedback to teaching hospitals.

Monocyte activation in peripheral blood and dialyser eluates: phenotypic profile and cytokine release.

BACKGROUND/AIMS: Monocyte activation and subsequent cytokine generation is presumed to be involved in haemodialysis (HD)-related morbidity. The present study was designed to investigate HD-induced changes in monocytes, with respect to their phenotypic profile and cytokine release, both in peripheral blood (PB) and dialyser eluates (DE). In addition, the effect of the type of dialyser on monocyte activation was assessed. METHODS: Dialyser elution was performed in 8 patients after 3 h of HD, using cuprammonium (CU) and polysulfon (PS) dialysers in a randomised cross-over design. PB samples and DE were analysed for both the expression of a variety of monocyte cell surface markers (CD62L, CD11b, CD25, HLA-DR, CD64 and CD14) by flow cytometry and IL-1beta levels. Monocytes were identified by dual labelling with antibodies against CD14. RESULTS: In PB, the expression of CD11b increased during HD with both devices, but was more pronounced with CU (CU versus PS: p < 0.05). CD62L decreased during HD, but only significantly for PS (p < 0.02). HLA-DR was downregulated during HD with CU (p = 0.056). The expression of CD64 was higher during HD with CU (p = 0.02). Finally, CD14 increased during HD with both dialysers (p < 0.03). DE yielded a mean cell count of 51 x 10(6) cells. The proportion of monocytes in DE was 3% for CU and 4% for PS. In eluted monocytes, a significant upregulation of CD11b, CD25, and HLA-DR was observed. CD62L was downregulated when compared to PB at t(180) (p < 0.001). In DE, no correlation was found between the type of dialyser and the phenotypic changes. In 10 of 16 DE supernatants, 6 CU and 4 PS, IL-1beta release could be demonstrated, CU yielding significantly more of this cytokine than PS (p = 0.03). CONCLUSIONS: According to both their phenotypic profile and cytokine release, monocytes sticking to the dialyser membrane after HD are considerably more activated than circulating monocytes. Activation of eluted monocytes appeared independent of the type of dialyser, suggesting an effect of mechanical stress rather than bioincompatibility. In contrast, phenotypic activation of peripheral blood monocytes and cytokine release in the DE supernatant were mainly dialyser-dependent.