RESUMEN
BACKGROUND: HIV incidence and mortality are increasing in Ukraine despite their reductions globally, in part due to suboptimal antiretroviral therapy (ART) coverage in key populations of people with HIV (PWH) where the epidemic is concentrated. As physicians are gatekeepers to ART prescription, stigma and discrimination barriers are understudied as a key to meeting HIV treatment targets in key populations. METHODS: A national sample (N = 204) of ART-prescribing physicians in Ukraine were surveyed between August and November 2019. Participants underwent a series of randomized, hypothetical HIV clinical scenarios and decided whether to initiate or defer (or withhold) ART. Scenarios varied based on 5 distinct CD4 counts (CD4: 17, 176, 305, 470, or 520 cells/mL) and 10 different PWH key populations. Z scores and McNemar's test for paired samples were used to assess differences between key populations and CD4 count. Feeling thermometers were used to assess stigma-related measures toward key populations among physicians. RESULTS: Physicians were highly experienced (mean = 19 years) HIV treaters, female (80.4%), and trained in infectious diseases (76.5%). Patients who drink alcohol (range: 21.6%-23.5%) or use (PWUD range: 16.7%-20.1%) or inject (PWID range: 15.5%-20.1%) drugs were most likely to have ART deferred, even at AIDS-defining CD4 counts. PWID maintained on methadone, however, were significantly (p<0.001) less likely to have ART deferred compared with those who were not (range: 7.8%-12.7%) on methadone. Men who have sex with men (range: 5.4%-10.8%), transgender women (range: 4.9%-11.3%), sex workers (range: 3.9%-10.3%),and having an HIV-uninfected sex partner (range: 3.9%-9.3%) had the lowest likelihood of ART deferral. Increasing levels of stigma (i.e., feeling thermometers) towards a key population was correlated with ART deferral (i.e., discrimination). CONCLUSIONS: Despite international and Ukrainian guidelines recommending ART prescription for all PWH, irrespective of risk or CD4 count, ART deferral by experienced HIV experts remains high in certain key populations, especially in PWH and substance use disorders. Strategies that initiate ART immediately after diagnosis (i.e., rapid start antiretroviral therapy), independent of risk group, should be prioritized to truly mitigate the current epidemic.
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Infecciones por VIH , Médicos , Trastornos Relacionados con Sustancias , Humanos , Ucrania/epidemiología , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Masculino , Femenino , Adulto , Médicos/psicología , Trastornos Relacionados con Sustancias/epidemiología , Persona de Mediana Edad , Recuento de Linfocito CD4 , Fármacos Anti-VIH/uso terapéutico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Encuestas y Cuestionarios , Estigma SocialRESUMEN
Little is known about the burden of silicosis in Africa, despite extensive mining and construction operations in the region putting numerous people at risk. The implementation experience and costs of case-finding for occupational lung disease in resource-limited settings are also currently unknown. We describe the first-ever silicosis case-finding project in rural Rwanda using chest X-ray, symptom questionnaires, and spirometry. This was coupled with routine noncommunicable disease case-finding for diabetes and hypertension. We performed an ingredient-based analysis of the costs of all case-finding activities. In 2022, over 25 days, 1,032 mine workers were included in the program, of which 1,014 (98.3%) completed silicosis case-finding activities. The total cost of the program was estimated to be US$38,656, representing a cost of US$37.49 per person. We conclude that conducting large-scale occupational lung disease case-finding is clinically and economically feasible in resource-limited settings and can be effectively integrated with routine noncommunicable disease case-finding.
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Población Rural , Silicosis , Humanos , Silicosis/economía , Rwanda , Masculino , Minería/economía , Costos y Análisis de Costo , Adulto , Mineros , Espirometría , Persona de Mediana Edad , Enfermedades Profesionales/economía , Encuestas y CuestionariosRESUMEN
Recent guidelines and recommen dations from government prevention advisory groups endorsing shared clinical decision-making reflect an emerging trend among public health bodies.
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Toma de Decisiones Clínicas , Salud Pública , Toma de Decisiones , HumanosRESUMEN
BACKGROUND: Meniere's disease (MD)-associated benign paroxysmal positional vertigo (BPPV) is complex and difficult to diagnose, and reports of its prevalence, pathologic features and outcomes are sparse and conflicting. OBJECTIVE: Report disease characteristics and outcomes associated with the presence of MD in patients with BPPV. MATERIALS/METHODS: A retrospective study of patients with BPPV between 2007 and 2017 at a single, high-volume institution. RESULTS: Of 1581 patients with BPPV identified, 7.1% had MD and 71.9% of those patients had BPPV in the same ear(s) as MD. Patients with MD were more likely to have lateral semicircular canalithiasis (11.6% vs. 5.5%, p = .009) and multiple canalithiasis (7.1% vs. 2.5%, p = .005). MD was associated with an increased rate of resolution of BPPV (p = .008) but also increased time to resolution (p = .007). There was no association between MD and recurrence of BPPV. CONCLUSIONS: MD is associated with lateral canalithiasis. Contrary to prior reports, BPPV in MD can affect either ear and was not associated with poorer outcomes than idiopathic BPPV. SIGNIFICANCE: The largest series to date investigating disease and outcome characteristics for BPPV in MD is presented. These data inform diagnosis and expectations in the management of these complex patients.
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Vértigo Posicional Paroxístico Benigno/epidemiología , Vértigo Posicional Paroxístico Benigno/terapia , Enfermedad de Meniere/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Vértigo Posicional Paroxístico Benigno/patología , Femenino , Humanos , Masculino , Enfermedad de Meniere/patología , Enfermedad de Meniere/terapia , Persona de Mediana Edad , Recurrencia , Estudios Retrospectivos , Canales Semicirculares/patología , Resultado del TratamientoRESUMEN
OBJECTIVE: To report treatment of benign paroxysmal positional vertigo (BPPV) in patients unable to undergo traditional canalith repositioning maneuvers (CRMs) using a particle repositioning chair (PRC). METHODS: A retrospective chart review was conducted at a single high-volume otology practice of patients diagnosed with BPPV from 2007 to 2017 with immobility prohibiting use of traditional CRMs. Patients were diagnosed and treated using a PRC, and outcome measures including resolution, recurrence, and number of treatment visits were recorded. RESULTS: A total of 34 patients meeting criteria were identified, 24 of whom had cervical spine disease and 10 of whom had other prohibitive immobility. Symptoms were present for between 5 days and 11 years at presentation, with mean and median of 552 and 90 days, respectively. Symptoms resolved in 68% of patients and recurred in 13% of those patients. Most patients required 1 treatment visit. CONCLUSIONS: Successful treatment of patients with BPPV and concomitant immobility prohibiting traditional CRMs is reported using the PRC. Benign paroxysmal positional vertigo in the setting of immobility is an indication for treatment with a PRC if available.
Asunto(s)
Vértigo Posicional Paroxístico Benigno/terapia , Limitación de la Movilidad , Posicionamiento del Paciente/instrumentación , Adulto , Anciano , Anciano de 80 o más Años , Vértigo Posicional Paroxístico Benigno/complicaciones , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: To report rates of recurrence in benign paroxysmal positional vertigo (BPPV) and associated patient and disease factors. STUDY DESIGN: Retrospective chart review. SETTING: Single high-volume otology practice. PATIENTS: Patients diagnosed with BPPV from 2007 to 2016 with documented resolution of symptoms. INTERVENTION: Diagnostic and particle repositioning maneuvers for BPPV. MAIN OUTCOME MEASURES: BPPV recurrence, time to recurrence, and ear(s) affected at recurrence. RESULTS: A total of 1,105 patients meeting criteria were identified. Of this population, 37% had recurrence of BPPV in either ear or both ears. Overall same-ear recurrence rate was 28%; 76% of recurrences involved the same ear(s) as initial presentation. Recurrences that occurred after longer disease-free intervals were more likely to involve the opposite ear than early recurrences (pâ=â0.02). Female sex (40.4% versus 32.7%, pâ=â0.01) and history of previous BPPV (57.5% versus 32.4%, pâ<â0.0005) were associated with increased risk of recurrence, while history of Menière's disease, diabetes mellitus, and traumatic etiology were not. Approximately, half (56%) of recurrences occurred within 1 year of resolution. CONCLUSIONS: A large single-institution study of recurrence in BPPV is presented along with Kaplan-Meier disease-free survival curves. Female sex and history of previous BPPV were associated with increased recurrence, while previously suspected risk factors for recurrence including history of Menière's disease, diabetes, and trauma were not. Remote recurrence is more likely to involve the contralateral ear than early recurrence. These data solidify the expected course of treated BPPV allowing for improved clinical care and patient counseling.
Asunto(s)
Vértigo Posicional Paroxístico Benigno/epidemiología , Vértigo Posicional Paroxístico Benigno/terapia , Adulto , Anciano , Femenino , Humanos , Incidencia , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Posicionamiento del Paciente/métodos , Recurrencia , Estudios Retrospectivos , Factores de RiesgoRESUMEN
PURPOSE: Benign paroxysmal positional vertigo (BPPV) involving the horizontal and superior semicircular canals is difficult to study due to variability in diagnosis. We aim to compare disease, treatment, and outcome characteristics between patients with BPPV of non-posterior semicircular canals (NP-BPPV) and BPPV involving the posterior canal only (P-BPPV) using the particle repositioning chair as a diagnostic and therapeutic tool. METHODS: Retrospective review of patients diagnosed with and treated for BPPV at a high volume otology institution using the particle repositioning chair. RESULTS: A total of 610 patients with BPPV were identified, 19.0% of whom had NP-BPPV. Patients with NP-BPPV were more likely to have bilateral BPPV (52.6% vs. 27.6%, pâ¯<â¯0.0005) and Meniere's disease (12.1% vs. 5.9%, pâ¯=â¯0.02) and were more likely to have caloric weakness (40.3% vs. 24.3%, pâ¯=â¯0.01). Patients with NP-BPPV required more treatments for BPPV (average 3.4 vs. 2.4, pâ¯=â¯0.01) but did not have a significantly different rate of resolution, rate of recurrence, or time to resolution or recurrence than patients with posterior canal BPPV. CONCLUSIONS: Comparison of NP-BPPV and P-BPPV is presented with reliable diagnosis by the particle repositioning chair. NP-BPPV affects 19% of patients with BPPV, and these patients are more likely to have bilateral BPPV and to require more treatment visits but have similar outcomes to those with P-BPPV. NP-BPPV is common and should be part of the differential diagnosis for patients presenting with positional vertigo.