RÉSUMÉ
The rapidly growing population of asylum seekers in the United States often seeks asylum following persecution and severe traumatic events. Asylum evaluations play an influential role in the process by objectively documenting human rights abuses. The purpose of this study was to describe the prevalence of major depressive disorder (MDD) and anxiety disorders among asylum seekers and analyze differences in the severity of disease by time and sub-group. Data was collected from a retrospective review of medical affidavits written from 2017 to 2020 following asylum evaluations in South Florida. Decision trees were utilized to make diagnoses for each individual's current mental health status in the U.S. and retrospectively for while in their home country. These diagnoses were recorded according to the Global Burden of Disease study criteria and utilizing validated mental health screeners. The prevalence of MDD was found to significantly decrease from 75.8% in patients' home countries to 46.7% in the U.S. Similarly, prevalence of anxiety disorders significantly fell from 85.8% to 64.2%. Gender and being a victim of sexual assault were significantly associated with severity of MDD and anxiety disorders. This reduction in the burden of mental health disease after relocation to the United States demonstrate the benefit of asylum not only as a human right, but also as a mental health intervention. Through their connection with higher application success rates and referrals to follow-up care, physician-performed asylum evaluations can thus be linked to improved health outcomes.
Sujet(s)
Trouble dépressif majeur , Réfugiés , Troubles de stress post-traumatique , Humains , États-Unis , Trouble dépressif majeur/épidémiologie , Troubles de stress post-traumatique/diagnostic , Floride/épidémiologie , Réfugiés/psychologie , Prévalence , Études rétrospectives , Troubles anxieux/épidémiologieRÉSUMÉ
OBJECTIVE: Asylum seekers experience a high burden of physical and psychological trauma, yet there is a scarcity of literature regarding the epidemiology and sequelae of head injury (HI) in asylum seekers. We examined HI prevalence and association with neuropsychiatric comorbidities in asylum seekers. METHODS: A retrospective cross-sectional study was performed through review of 139 medical affidavits from an affidavit database. Affidavits written from 2010 to 2018 were included. Demographic and case-related data were collected and classified based on the presence of HI. For neuropsychiatric sequelae, the primary study outcome was headache and the secondary outcomes were depression, posttraumatic stress disorder, and anxiety. Multivariable logistic regression was performed to examine the association between HI and neuropsychiatric sequelae, adjusted for demographic and clinical characteristics. RESULTS: A total of 139 medical affidavits of asylum seekers were included. The mean age was 27.4 ± 12.1 years, 56.8% were female, and 38.8% were <19 years. Almost half (42.5%) explicitly self-reported history of HI. Compared to clients who did not report HI, clients with HI were older and more likely to report a history of headache, physical abuse, physical trauma, concussion, and loss of consciousness. After adjustment for demographic and clinical characteristics, clients with HI had greater odds for neuropsychological sequelae such as headache (odds ratio [OR] 4.2, 95% confidence interval [CI] 2.0-8.7) and depression (OR 2.5, 95% CI 1.1-5.7). CONCLUSIONS: We observed a high prevalence of HI in asylum seekers. Comprehensive screening for HI and neuropsychiatric comorbidities is encouraged when evaluating asylum seekers.
Sujet(s)
Anxiété/épidémiologie , Traumatismes cranioencéphaliques/épidémiologie , Dépression/épidémiologie , Céphalée/épidémiologie , Réfugiés/statistiques et données numériques , Troubles de stress post-traumatique/épidémiologie , Violence/statistiques et données numériques , Adolescent , Adulte , Anxiété/psychologie , Commotion de l'encéphale/épidémiologie , Commotion de l'encéphale/psychologie , Traumatismes cranioencéphaliques/psychologie , Études transversales , Dépression/psychologie , Salvador/ethnologie , Femelle , Guatemala/ethnologie , Haïti/ethnologie , Céphalée/psychologie , Honduras/ethnologie , Humains , Mâle , Troubles de la mémoire/épidémiologie , Troubles de la mémoire/psychologie , Mexique/ethnologie , Nicaragua/ethnologie , Odds ratio , Questionnaire de santé du patient , Prévalence , Traumatisme psychologique/épidémiologie , Traumatisme psychologique/psychologie , Réfugiés/psychologie , Études rétrospectives , Répartition par sexe , Infractions sexuelles/psychologie , Infractions sexuelles/statistiques et données numériques , Troubles de l'endormissement et du maintien du sommeil/épidémiologie , Troubles de l'endormissement et du maintien du sommeil/psychologie , Troubles de stress post-traumatique/psychologie , Perte de conscience/épidémiologie , Perte de conscience/psychologie , États-Unis/épidémiologie , Plaies et blessures/épidémiologie , Plaies et blessures/psychologie , Jeune adulteRÉSUMÉ
Miami-Dade County (MDC) represents a major port of entry for people seeking asylum in the United States, and few studies have systematically evaluated the demographic characteristics of this vulnerable population. Moreover, while the burden of post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) are thought to be higher in this population, the prevalence of these psychiatric conditions in our community is unknown. An analysis of demographics and psychiatric co-morbidities of the Human Rights Clinic (HRC) of Miami's 93 clients between 2010 and 2015 was conducted. The HRC cohort had the following characteristics: median age of 30 years, 52% female, 46% male, 2% transgender or intersex, and 88% originating from Latin America and the Caribbean. The prevalence of PTSD was 67% and MDD was 53% in the HRC population. We conclude that the mental health burden in asylum-seekers in MDC is alarmingly high and that healthcare providers should remain keenly attentive to the unique needs of this population.
RÉSUMÉ
PURPOSE: Non-adherence to tuberculosis therapy can lead to drug resistance, prolonged infectiousness, and death; therefore, understanding what causes treatment default is important. Pakistan has one of the highest burdens of tuberculosis in the world, yet there have been no qualitative studies in Pakistan that have specifically examined why default occurs. We conducted a mixed methods study at a tuberculosis clinic in Karachi to understand why patients with drug-susceptible tuberculosis default from treatment, and to identify factors associated with default. Patients attending this clinic pick up medications weekly and undergo family-supported directly observed therapy. METHODS: In-depth interviews were administered to 21 patients who had defaulted. We also compared patients who defaulted with those who were cured, had completed, or had failed treatment in 2013. RESULTS: Qualitative analyses showed the most common reasons for default were the financial burden of treatment, and medication side effects and beliefs. The influence of finances on other causes of default was also prominent, as was concern about the effect of treatment on family members. In quantitative analysis, of 2120 patients, 301 (14.2%) defaulted. Univariate analysis found that male gender (OR: 1.34, 95% CI: 1.04-1.71), being 35-59 years of age (OR: 1.54, 95% CI: 1.14-2.08), or being 60 years of age or older (OR: 1.84, 95% CI: 1.17-2.88) were associated with default. After adjusting for gender, disease site, and patient category, being 35-59 years of age (aOR: 1.49, 95% CI: 1.10-2.03) or 60 years of age or older (aOR: 1.76, 95% CI: 1.12-2.77) were associated with default. CONCLUSIONS: In multivariate analysis age was the only variable associated with default. This lack of identifiable risk factors and our qualitative findings imply that default is complex and often due to extrinsic and medication-related factors. More tolerable medications, improved side effect management, and innovative cost-reduction measures are needed to reduce default from tuberculosis treatment.
Sujet(s)
Antituberculeux/usage thérapeutique , Thérapie sous observation directe/statistiques et données numériques , Observance par le patient/statistiques et données numériques , Tuberculose/traitement médicamenteux , Adolescent , Adulte , Sujet âgé , Sujet âgé de 80 ans ou plus , Enfant , Enfant d'âge préscolaire , Thérapie sous observation directe/méthodes , Femelle , Humains , Nourrisson , Nouveau-né , Entretiens comme sujet , Mâle , Adulte d'âge moyen , Analyse multifactorielle , Pakistan , Observance par le patient/psychologie , Recherche qualitative , Études rétrospectives , Facteurs de risque , Échec thérapeutiqueRÉSUMÉ
AIDS-related mortality remains a leading cause of preventable death among African-Americans. We sought to determine if community health workers could improve clinical outcomes among vulnerable African-Americans living with HIV in Miami, Florida. We recruited 91 medically indigent persons with HIV viral loads ≥1,000 and/or a CD4 cell count ≤350. Patients were randomized to a community health worker (CHW) intervention or control group. Viral load and CD4 cell count data were abstracted from electronic medical records. At 12 months, the mean VL in the intervention group was log 0.9 copies/µL lower than the control group. The CD4 counts were not significantly different among the groups. Compared to the control group, patients randomized to CHWs experienced statistically significant improvements in HIV viral load. Larger multi-site studies of longer duration are needed to determine whether CHWs should be incorporated into standard treatment models for vulnerable populations living with HIV.
Sujet(s)
Thérapie antirétrovirale hautement active , , Agents de santé communautaire/statistiques et données numériques , Infections à VIH/thérapie , Services de soins à domicile , Adhésion au traitement médicamenteux/statistiques et données numériques , Acceptation des soins par les patients/statistiques et données numériques , Adolescent , Adulte , /psychologie , Numération des lymphocytes CD4 , Agents de santé communautaire/normes , Femelle , Floride/épidémiologie , Études de suivi , Infections à VIH/épidémiologie , Infections à VIH/psychologie , Services de soins à domicile/organisation et administration , Humains , Mâle , Adhésion au traitement médicamenteux/psychologie , Adulte d'âge moyen , Acceptation des soins par les patients/psychologie , Satisfaction des patients , Évaluation de programme , Facteurs socioéconomiques , Enquêtes et questionnaires , Résultat thérapeutique , Charge viraleSujet(s)
Dossiers médicaux électroniques , Gestion des connaissances , Logiciel , Humains , Médecins , Projets pilotesRÉSUMÉ
We examined alcohol use patterns and adherence to antiretroviral therapy (ART) among 45 people living with HIV (PLWH) in Miami, Florida. Documented provider knowledge of alcohol use was also assessed. Among our sample, 20 % reported "weekending," a phenomenon we describe as skipping ART due to planned alcohol use and drinking more on the weekend. While 100 % of our sample reported alcohol use, 73 % of providers' notes reported abstinence. Until larger studies assess the generalizability of these findings among other PLWH, providers should consider probing patients about when they drink, how much they drink, and if they take ART when drinking.
Sujet(s)
Consommation d'alcool/psychologie , Agents antiVIH/usage thérapeutique , Hyperalcoolisation rapide/psychologie , Infections à VIH/traitement médicamenteux , Adhésion au traitement médicamenteux , Adulte , Sujet âgé , Consommation d'alcool/épidémiologie , Hyperalcoolisation rapide/épidémiologie , Numération des lymphocytes CD4 , Communication , Études transversales , Femelle , Floride/épidémiologie , Infections à VIH/psychologie , Comportement en matière de santé , Connaissances, attitudes et pratiques en santé , Humains , Mâle , Adulte d'âge moyen , Projets pilotes , Relations entre professionnels de santé et patients , Enquêtes et questionnairesSujet(s)
Tumeurs de l'anus/diagnostic , Prestation intégrée de soins de santé , Infections à VIH/thérapie , États précancéreux/diagnostic , Soins de santé primaires/organisation et administration , Service de santé pour les femmes/organisation et administration , Tumeurs de l'anus/complications , Tumeurs de l'anus/thérapie , Femelle , Infections à VIH/complications , Infections à VIH/traitement médicamenteux , Humains , Adulte d'âge moyen , États précancéreux/complications , États précancéreux/thérapieRÉSUMÉ
OBJECTIVES: To validate the use of a script concordance test (SCT), a tool to assess clinical reasoning in contexts of uncertainty, which are common in clinical geriatrics practice, on geriatric urinary incontinence (UI) to discriminate levels of expertise in this content area. DESIGN: A reference panel (15 geriatricians) and 12 respondents (10 senior geriatrics fellows and 2 interns) completed an online 100-item SCT test covering major topics in UI. The test was then optimized by discarding items with negative item-total correlation; the remaining 70 questions covered all major topics in UI. The test was then administered to a second group of participants with different levels of experience, mostly from the University of Miami: eight geriatricians, nine junior geriatrics fellows, 53 internal medicine residents, and 26 medical students. Investigators assessed test reliability and construct validity (to discriminate between levels of expertise). SETTING: Tertiary academic medical center and affiliated medical school. PARTICIPANTS: Medical students, internal medicine residents, geriatric medicine fellows, and practicing geriatricians. MEASUREMENTS: Seventy-item SCT. RESULTS: The Cronbach alpha for the 70-item test was 0.72. Mean scores were 75.3 ± 7.9 for geriatricians (n = 23), 69.0 ± 9.3 for senior geriatrics fellows (n = 10), 66.4 ± 6.8 for junior geriatrics fellows n = (9), 66.1 ± 5.7 for residents (n = 53), and 65.6 ± 8.5 for students (n = 26). Using analysis of variance, significant differences were found between the mean scores of the geriatricians and all other participants except senior fellows. CONCLUSION: The geriatric UI SCT demonstrated moderate reliability and evidence of construct validity, discriminating between experienced and nonexperienced physicians.
Sujet(s)
Compétence clinique , Gériatrie/enseignement et éducation , Incontinence urinaire , Humains , Incontinence urinaire/diagnosticRÉSUMÉ
BACKGROUND: Human immunodeficiency virus (HIV)-associated tuberculosis is difficult to treat, given the propensity for drug interactions between the rifamycins and the antiretroviral drugs. We examined the pharmacokinetics of rifabutin before and after the addition of lopinavir-ritonavir. METHODS: We analyzed 10 patients with HIV infection and active tuberculosis in a state tuberculosis hospital. Plasma was collected for measurement of rifabutin, the microbiologically active 25-desacetyl-rifabutin, and lopinavir by validated high-performance liquid chromatography assays. Samples were collected 2-4 weeks after starting rifabutin at 300 mg thrice weekly without lopinavir-ritonavir, 2 weeks after the addition of lopinavir-ritonavir at 400 and 100 mg, respectively, twice daily to rifabutin at 150 mg thrice weekly, and (if rifabutin plasma concentrations were below the normal range) 2 weeks after an increase in rifabutin to 300 mg thrice weekly with lopinavir-ritonavir. Noncompartmental and population pharmacokinetic analyses (2-compartment open model) were performed. RESULTS: Rifabutin at 300 mg without lopinavir-ritonavir produced a low maximum plasma concentration (C(max)) in 5 of 10 patients. After the addition of lopinavir-ritonavir to rifabutin at 150 mg, 9 of 10 had low C(max) values. Eight patients had dose increases to 300 mg of rifabutin with lopinavir-ritonavir. Most free rifabutin (unbound to plasma protein) C(max) values were below the tuberculosis minimal inhibitory concentration. For most patients, values for the area under the plasma concentration-time curve were as low or lower than those associated with treatment failure or relapse and with acquired rifamycin resistance in Tuberculosis Trials Consortium/US Public Health Service Study 23. One of the 10 patients experienced relapse with acquired rifamycin resistance. CONCLUSION: The recommended rifabutin doses for use with lopinavir-ritonavir may be inadequate in many patients. Monitoring of plasma concentrations is recommended.
Sujet(s)
Antibiotiques antituberculeux/pharmacocinétique , Antiviraux/pharmacocinétique , Infections à VIH/complications , Infections à VIH/traitement médicamenteux , Pyrimidinones/pharmacocinétique , Rifabutine/pharmacocinétique , Ritonavir/pharmacocinétique , Tuberculose/complications , Tuberculose/traitement médicamenteux , Adulte , Antibiotiques antituberculeux/sang , Antibiotiques antituberculeux/usage thérapeutique , Antiviraux/sang , Antiviraux/usage thérapeutique , Interactions médicamenteuses , Femelle , Humains , Lopinavir , Mâle , Adulte d'âge moyen , Pyrimidinones/sang , Pyrimidinones/usage thérapeutique , Rifabutine/sang , Rifabutine/usage thérapeutique , Ritonavir/sang , Ritonavir/usage thérapeutiqueSujet(s)
Infections opportunistes liées au SIDA/microbiologie , Syndrome d'immunodéficience acquise/microbiologie , Pneumocystis carinii , Pneumonie à Pneumocystis/virologie , Embolie pulmonaire/virologie , Infections opportunistes liées au SIDA/diagnostic , Infections opportunistes liées au SIDA/traitement médicamenteux , Syndrome d'immunodéficience acquise/complications , Syndrome d'immunodéficience acquise/virologie , Adulte , Femelle , Humains , Mâle , Pneumonie à Pneumocystis/diagnostic , Pneumonie à Pneumocystis/traitement médicamenteux , Embolie pulmonaire/microbiologieSujet(s)
Infections opportunistes liées au SIDA/complications , Agents antiVIH/usage thérapeutique , Vertèbres lombales , Infection due à Mycobacterium avium-intracellulare/complications , Ostéomyélite/complications , Infections opportunistes liées au SIDA/traitement médicamenteux , Infections opportunistes liées au SIDA/immunologie , Adulte , Thérapie antirétrovirale hautement active , Antituberculeux/usage thérapeutique , Numération des lymphocytes CD4 , Études de suivi , VIH (Virus de l'Immunodéficience Humaine) , Humains , Mâle , Complexe Mycobacterium avium/isolement et purification , Infection due à Mycobacterium avium-intracellulare/traitement médicamenteux , Infection due à Mycobacterium avium-intracellulare/immunologie , Ostéomyélite/traitement médicamenteux , Ostéomyélite/microbiologieRÉSUMÉ
The clinical presentation of colitis associated with Clostridium difficile infection in immunosuppressed patients with acquired immunodeficiency syndrome (AIDS) has not been completely characterized. Previous reports suggest that these patients present with low blood leukocyte counts, consistent with the impaired myelopoiesis that can occur with human immunodeficiency virus (HIV) infection. In contrast, we describe the cases of two patients with colitis associated with C difficile infection who developed intense leukemoid reactions despite being in advanced stages of AIDS. To the best of our knowledge, these are the first described cases of leukemoid reaction associated with C difficile or other bacterial infection in AIDS patients. We review the literature on C difficile colitis in patients infected with HIV and suggest that severe C difficile infection should be considered in such patients presenting with leukemoid reaction and diarrhea.
Sujet(s)
Infections opportunistes liées au SIDA/immunologie , Syndrome d'immunodéficience acquise/immunologie , Clostridioides difficile , Entérocolite pseudomembraneuse/immunologie , Sujet immunodéprimé , Réaction leucémoïde/microbiologie , Adulte , Issue fatale , Femelle , Humains , Mâle , Adulte d'âge moyenRÉSUMÉ
BACKGROUND: The purpose of the study was to examine the relationship between age and plasma viral load in HIV-1-infected individuals. DESIGN: The experimental method was to recruit older (> 50 years of age) and younger (18-39 years of age) HIV-1-infected individuals. The plasma viral load was measured using the Roche Molecular Systems UltraSensitive Roche HIV-1 Monitor test reflexively with the standard Amplicor HIV Monitor test to quantify viral load in the range of 50-750,000 copies of HIV-1 RNA/ml plasma. SUBJECTS: A total of 135 HIV-1-seropositive individuals (at Centers for Disease Control and Prevention early symptomatic stage B or late symptomatic stage/AIDS C) were enrolled as part of a larger cohort also consisting of HIV-1-seronegative individuals. RESULTS: A generalized linear models statistical analysis was conducted in order to evaluate age category as a predictor of plasma viral load. The result was a significant effect of age category, with older age associated with a lower plasma viral load. The association held controlling for antiretroviral therapy usage, disease stage, antiretroviral medication adherence, HIV-1 serostatus duration, alcohol and substance use, recent sexually transmitted disease, and sociodemographics (except income). CONCLUSION: Older age was associated with lower levels of HIV-1 replication in this sample, independent of antiretroviral therapy usage, regimen adherence, and disease stage. It is suggested that the effect may be caused by changes in viral evolution or immunological monitoring specific to older individuals with HIV-1 infection.
Sujet(s)
Vieillissement/physiologie , Infections à VIH/physiopathologie , VIH-1 (Virus de l'Immunodéficience Humaine de type 1) , Charge virale , Adulte , Facteurs âges , Consommation d'alcool , Thérapie antirétrovirale hautement active , Numération des lymphocytes CD4 , Femelle , Infections à VIH/virologie , Séropositivité VIH/physiopathologie , Séropositivité VIH/virologie , Humains , Modèles linéaires , Mâle , Adulte d'âge moyen , Observance par le patient , ARN viral/analyse , Maladies sexuellement transmissibles/complications , Troubles liés à une substance/complicationsRÉSUMÉ
In young adults, a major neurologic complication of HIV-1 infection is cognitive motor impairment. Epidemiologic findings suggest that increasing age is a significant risk factor for HIV-1-associated dementia as the AIDS-defining illness. Findings from the few studies that have directly measured cognition in younger and older HIV-1-infected adults, however, have been mixed, in part, because of small sample sizes and other methodologic differences between studies. The authors present preliminary findings on cognitive functioning in symptomatic HIV-1-infected younger (aged 20-39 years) and older (aged 50 years or older) adults. Independent of age, HIV-1 infection was accompanied by learning and memory retrieval deficits, which were significantly associated with high plasma viral loads in the young adults. Relative to the younger and older HIV-1-negative (HIV-1-) groups, only the younger HIV-1-positive (HIV-1+) group had significantly longer reaction times (RTs). Within the older HIV-1+ group, however, longer simple and choice RTs were significantly correlated with higher viral loads and lower CD4 cell counts. Although HIV-1 infection affects cognition independent of age, longitudinal studies involving large numbers of older individuals are needed to determine whether there are age differences in the prevalence, nature, and severity of HIV-1-associated cognitive dysfunction.
Sujet(s)
Syndrome d'immunodéficience acquise/psychologie , Vieillissement/physiologie , Cognition/physiologie , Infections à VIH/psychologie , VIH-1 (Virus de l'Immunodéficience Humaine de type 1) , Syndrome d'immunodéficience acquise/physiopathologie , Adulte , Attention/physiologie , Ethnies , Femelle , Infections à VIH/physiopathologie , Humains , Apprentissage/physiologie , Mâle , Mémoire/physiologie , Adulte d'âge moyen , Analyse multifactorielle , Temps de réaction , États-UnisRÉSUMÉ
BACKGROUND: Objective evaluations of residents' clinical skills reveal serious deficits. PURPOSE: To develop, implement, and evaluate outcomes from a review course in cardiology bedside skills for internal medicine residents. METHODS: We used a 1-group pretest-posttest design with historical comparisons. The study was conducted at the University of Miami School of Medicine as part of the internal medicine residency program from July 1999 to June 2000. A total of 67 2nd- and 3rd-year medicine residents received an educational intervention involving deliberate practice using simulation technology. A total of 155 4th-year medical students in one intervention and one comparison group (n = 53) served as historical comparisons. Outcome measures were a reliable computer-delivered pretest and posttest that evaluate cardiology bedside skills. RESULTS: Residents who received the review course and medical students who received a comparable educational intervention showed large and statistically significant pretest-to-posttest improvement in bedside skills. These 2 groups are also significantly and substantially different at posttest from a comparison group of 4th-year medical students that did not receive a specific educational intervention. CONCLUSION: Educational interventions using simulation technology that engage learners in deliberate practice of clinical skills produce large improvements in a relatively short time, with little faculty involvement.