Highly active antiretroviral therapy outcomes in a primary care clinic.

This paper compares antiretroviral outcomes of patients at a primary care clinic with those previously reported at HIV specialty clinics and examines risk factors for treatment failure. A retrospective medical record review was undertaken at an academic primary care practice in Baltimore, Maryland. One hundred and twenty-three patients were included who had not previously received HAART and who were started on a regimen that included a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor and at least one other new antiretroviral medication. HIV RNA levels, CD4 lymphocyte counts, missed appointment rate, HAART regimen, demographic variables, and their association with the achievement of a viral RNA of 500 or less at 7-14 months were analyzed. Forty-seven per cent of the patients had an HIV RNA level of 500 or less at 7-14 months after initiation of HAART. Factors associated with treatment failure included missed appointment rate, injection drug use and previous exposure to antiretroviral medication. On multivariate analysis, only missed appointment rate and lower baseline CD4 lymphocyte count were independently associated with treatment failure. The antiretroviral outcomes of patients started on HAART by experienced health care providers in this primary care practice were comparable to those reported in specialty clinics. As with previous reports, most patients did not maintain viral suppression. Missed appointment rate was the most important risk factor for treatment failure.

Case report. Diagnosis of disseminated Mycobacterium avium complex infection by liver biopsy.

Mycobacterium avium complex (MAC) infection is a common complication of HIV/AIDS. Signs and symptoms of this infection are nonspecific and include fever, weight loss, diarrhea, and abnormal levels of liver enzymes, especially elevated alkaline phosphatase levels. Diagnosis can be achieved through several methods, but liver biopsy may be the most rapid and efficient. We present a case that illustrates the potential value of liver biopsy in diagnosing disseminated MAC infection.

A comparison of resource utilization in nurse practitioners and physicians.

CONTEXT: Nurse practitioners increasingly provide primary care in a variety of settings. Little is known about how resource utilization for patients assigned to nurse practitioners compares with that for patients assigned to physicians. OBJECTIVE: To compare health care resource utilization for adult patients assigned to a nurse practitioner with that for patients assigned to a resident or attending physician. DESIGN: Prospective, quasi-randomized study. SETTING: Primary care clinic at a Veterans Affairs medical center. PATIENTS: 450 new primary care patients: 150 were assigned to a nurse practitioner, 150 to a resident physician, and 150 to an attending physician. OUTCOME MEASURES: We collected data on laboratory and radiologic testing, specialty care, primary care, emergency or walk-in visits, and hospitalizations over a 1-year period. We also collected information on baseline chronic illnesses, blood pressure, and weight. RESULTS: Resource utilization for patients assigned to a nurse practitioner was higher than that for patients assigned to a resident in 14 of 17 utilization measures (3 were statistically significant) and higher in 10 of 17 measures when compared with patients assigned to an attending physician (3 were statistically significant). None of the utilization measures for patients in the nurse practitioner group was significantly lower than those for either physician group. CONCLUSIONS: In a primary care setting, nurse practitioners may utilize more health care resources than physicians.

Anomalous origin of the left coronary artery from the pulmonary artery associated with ventricular septal defect and mitral stenosis.

We report a case of a child with ventricular septal defect, mitral stenosis, and patent ductus arteriosus, who was also found to have anomalous origin of the left coronary artery from the pulmonary artery. Preoperative diagnosis allowed successful surgical correction.