Pre-exposure prophylaxis awareness, acceptability and potential stigma among medical and non-medical clinic staff in methadone treatment settings in northern New Jersey: The key role of non-medical staff in enhancing HIV prevention.

BACKGROUND: HIV prevention is needed among people who use drugs (PWUD) due to mixing sex and drugs, selling/trading sex, and/or injecting drugs. Pre-exposure prophylaxis (PrEP) is an extremely effective biomedical HIV prevention strategy, but uptake remains low among communities most in need of HIV prevention, including PWUD. Previous studies have found that providers are less willing to prescribe PrEP to PWUD, yet PWUD express high levels of PrEP acceptance. More research is needed to understand how people who provide substance use treatment services think about PrEP to maximize this biomedical prevention strategy. METHODS: The study conducted semistructured interviews with 29 staff members in two methadone clinic settings in urban northern New Jersey. Staff members included medical providers, methadone counselors, intake coordinators, front desk staff, lab technicians, security guards, and administrative/leadership personnel. RESULTS: All staff recognized the need for HIV prevention among their patient populations, but most were either unaware of PrEP or unfamiliar with its purpose and how it works. Medical providers were more likely to have some PrEP knowledge in comparison to counselors and other staff, but the former largely did not have in-depth knowledge. Among those familiar with PrEP, many confused PrEP with HIV medication, as Truvada was the only FDA-approved PrEP at the time of the study. About half of participants expressed clear support for PrEP, while the other half expressed mixed or negative attitudes related to HIV, sexual behavior, and mistrust of the medication. Both the positive and negative perceptions entailed stigmatizing elements. RECOMMENDATIONS: Due to patients' frequent interactions with non-medical staff (e.g., front desk staff, lab technicians, etc.), all staff, not only medical personnel, should be aware of PrEP and comfortable discussing it to foster well-informed, nonjudgmental conversations about HIV prevention with patients. PrEP education should specifically address HIV and sexual-related stigma, as even positive perceptions of PrEP may entail stigmatizing elements.

Correlates of PrEP Uptake Among Young Sexual Minority Men and Transgender Women in New York City: The Need to Reframe "Risk" Messaging and Normalize Preventative Health.

Pre-exposure prophylaxis (PrEP) is an effective form of HIV prevention, but young sexual minority men face myriad barriers to PrEP uptake. Participants (n = 202) completed a survey on healthcare experiences and beliefs about HIV and PrEP. While 98% of the sample knew about PrEP, only 23.2% reported currently taking PrEP. Participants were more likely to be taking PrEP if they received PrEP information from a healthcare provider and endorsed STI-related risk compensation. Conversely, PrEP uptake was less likely among those with concerns about medication use and adherence. While there were no racial/ethnic differences in PrEP uptake, there were differences in correlates of PrEP use for White participants and participants of color. To facilitate PrEP uptake, clinicians should provide PrEP education and screen all patients for PrEP candidacy. Additionally, public health messaging must reframe HIV "risk", highlight benefits of STI testing, and emphasize the importance of preventive healthcare for SMM.

[The use of therapeutic apheresis in neurological diseases and comparison between plasma exchange and immunoadsorption]. / Utilizzo dell'aferesi terapeutica in corso di patologie neurologiche comparazione tra plasmaexchange ed immunoadsorbimento.

The use of plasmapheresis in neurological diseases with immune-mediated pathogenesis is widely certified. In recent years, the technological evolution of the dialysis membranes allowed to accompany the classical plasma exchange (PEX) treatment of apheresis by means of selective adsorption (IA). It has proved to be of equal therapeutic efficacy and, at the same time, devoid of most of the PEX side effects. The recent guidelines of the American Society for Apheresis (ASFA) and, later, the American Academy of Neurology, outlined directions and diagrams for the application of the method that has found wide use in many neurological diseases on the basis of auto-antibodies; in particular in Myasthenia Gravis, Guillain-Barre Syndrome, Multiple Sclerosis and Chronic Demyelinating Polyradiculoneuropathy. We add our experience in the treatment of 13 patients suffering from Myasthenia Gravis, treated over a four years period with filters containing tryptophan immunoadsorption in polyvinyl alcohol gel. The results confirm the achievement of a rapid regression of clinical symptoms, together with the rapid fall in the levels of antibody against acetylcholine-receptor. Therefore, the method of AI is to be considered of equal therapeutic efficacy of PEX, providing greater security in its use.

New horizon in dialysis depuration: Characterization of a polysulfone membrane able to break the 'albumin wall'.

The uremic syndrome is attributed to the progressive retention of a large number of toxins, which under normal conditions are excreted by the healthy kidneys. Standard dialytic membranes do not purify middle-high molecular weight toxins. Haemodiafiltration with endogenous reinfusion coupled with a highly permeable membrane could break the limit of the 'albumin wall' improving the dialytic depuration without loss of important nutrients. The aim of this study was to evaluate the performance of a new polysulfone membrane, Synclear 0.2, to remove uremic molecules. Surface Enhanced Laser Desorption Ionization-Time of Flight was employed to evaluate the proteomic profile of ultrafiltrate and Electrospray Ionization-Quadruple-ToF coupled with on-chip elution was used for proteins identification. A high and specific permeability for middle-high molecular weight molecules was revealed by mass spectrometry for the investigated membrane. The identified proteins are mostly uremic toxins: their relative abundance, estimated in the ultrafiltrate by exponentially modified protein abundance index, showed a high purification efficiency of the new membrane when compared with conventional ones. In conclusion, Synclear 0.2, used as convective membrane in hemodiafiltration with endogenous reinfusion treatment, permits to break the 'albumin wall', clearing middle-high molecular weight uremic toxins, improving the dialytic treatment purification efficiency.

[Quality of life of the elderly patient on dialysis]. / La qualita' della vita nell'anziano in dialisi.

When elderly patients with end-stage renal disease start dialysis their quality of life, and particularly the emotional aspects of it, are very similar to those of age-matched controls. However, as the treatment becomes chronic the quality of life will decline not only with regard to the physical aspects (due to comorbidities) but also the emotional aspects. Dialysis-related stress episodes and the peculiar interrelationships in the dialysis facility setting may cause psychological discomfort which on the one hand reduces the patient's quality of life and on the other may unfavorably impact on the family and the health-care personnel. An integrated psychological approach involving the patient from the beginning of dialysis throughout the treatment process as well as the healthcare personnel and the family can reduce the patient's psychological discomfort, thereby improving quality of life.

[Nephrogenic systemic fibrosis]. / Fibrosi nefrogenica sistemica.

Nephrogenic systemic fibrosis (NSF) is a new, rare, and severe disease occurring in patients with renal failure who have been exposed to gadolinium. The pathogenesis of NSF is not completely known. In fact, the first warning about a significant relationship between NSF and gadolinium (a contrast medium used in magnetic resonance imaging) was only issued in 2006. No cases of NSF have been reported in Italy to date. A nationwide investigation should therefore be carried out to assess the real prevalence of NSF within the Italian uremic population. Furthermore, we need guidelines to reduce the risk of NSF in renal patients undergoing MRI with contrast medium.

[Dialysis, adaptation, quality of life, and family support]. / Rapporti tra adattamento, qualità di vita e supporto familiare, sociale nel paziente in trattamento dialitico.

Chronic dialysis treatment is characterized by a series of complex interdependent objective problems, such as the dialysis experience, the individual way to assess it, and some "protective" factors such as social and family support. Progresses in dialysis research show that dialysis patients have important alternatives to passively accept their condition: thanks to adequate psychological and relational aid, they can reach rather advanced adaptation levels, which allow them to modify both their behaviour and way of life, to keep a satisfactory compliance, and to improve their quality of life (QoL). In this adaptation process, both family and social support play an important role, although controversy still exists on it. The results of our study confirm the complexity of this role and show that either haemodialysis or peritoneal dialysis patients' adaptation process and QoL may be directly related to the extent of family member's ("caregiver") support. It is of particular interest the fact that patients, especially those undergoing haemodialysis, provided with a caregiver's assistance but who choose to "act by themselves", do have better adaptation levels and QoL than those who rely only on their caregiver. This fact reassesses the widely accepted point of view that continuous caregiver's support is always a positive and necessary factor in order to improve both the adaptation and the QoL of dialysis patients.

A napkin-associated outbreak of Burkholderia cenocepacia bacteraemia in haemodialysis patients.

This article reports a catheter-related outbreak of bacteraemia involving 38 patients in two haemodialysis units in Verona. Burkholderia cepacia complex strains were isolated from human blood and from an individually wrapped disinfection napkin that was contained in a commercially available, sterile dressing kit used to handle central venous catheters. Micro-organisms isolated from blood cultures and from the napkin were identified by standard procedures and confirmed as B. cenocepacia (genomovar III) by molecular analysis. Using pulsed-field gel electrophoresis analysis, the clinical isolates were indistinguishable or closely related to the B. cenocepacia isolated from the napkin. In conclusion, this study found that a contaminated commercial napkin soaked in quaternary ammonium, even when quality certified, was the source of infection.

Cutaneous plasmacytoma in a hemodialysis patient.

BACKGROUND: Extramedullary plasma cell dyscrasias are rare. CASE REPORT: We report a case of a 56-year-old male Caucasian hemodialysis patient with cutaneous plasmacytoma. The diagnosis was made a few months after surgical removal of his renal graft due to chronic rejection. Investigations for the presence of an associated myeloma were negative. He underwent local radiotherapy with complete resolution of the skin lesion. CONCLUSIONS: Nephrologists should be aware that the frequency of post-transplant lymphoproliferative disorders is increasing in the dialysis population, especially in those previously or currently treated with immunosuppressive drugs.

[Transfusional therapy of hemodialyzed patient with anti-Cartwright antibodies: case report and review of the literature]. / Terapia trasfusionale in un emodializzato con anticorpi anti-Cartwright: descrizione di un caso e revisione della litteratura.

BACKGROUND: Red cell Cartwright antigen (Yta) is very common in the general population therefore patients without red cell Cartwright antigen and with anti-Yta alloantibodies due to previous exposure to the antigen are rare. Report about clinical significance of Yta red cell alloantibodies in hemodialysis (HD) patients are scarce. CASE REPORT: We report a cirrhotic uremic patient with anti-Yta antibodies who received Yta positive red cells. No adverse reactions nor hemolysis were detected. CONCLUSIONS: We concluded that dialysis patients with anti-Yta antibodies could be safely transfused with blood from Cartwright positive donors.

[Diabetes and atherosclerotic coronary damage in uremia]. / Diabete e danno coronarico negli uremici.

BACKGROUND: Cardiovascular risk factors are common findings in uraemics, but the impact of each single factor on the development of atherosclerosis is still a matter of debate. PATIENTS AND METHODS: In order to evaluate the relationship between diabetes and ischaemic heart disease (IHD) in uraemia, we carried out a retrospective study comparing the results of 33 coronary angiographies performed in non-diabetic patients with those of 13 diabetics (2 had type 1 diabetes, 8 were treated with insulin, 2 with sulfonylureas and 3 received no therapy). Coronary angiography was performed in 29 patients awaiting kidney transplantation and in 17 subjects with IHD. RESULTS: Age, sex, length of time on renal replacement therapy, smoking history, clinical diagnosis of cerebrovascular and peripheral vascular disease, systolic blood pressure (BP), cholesterol, triglycerides, calcium, phosphate, albumin and degree of anaemia were comparable in the two groups. On the contrary, frequency of IHD (77 vs. 30%, p<0.01) and atrial fibrillation (23 vs. 3%, p<0.05) were higher, while diastolic BP (79 +/- 7 vs. 85 +/- 8 mmHg, p<0.05) and calcium phosphate product (47 +/- 10 vs. 57 +/- 15 mg2/dL2, p<0.05) were lower in diabetics than in non-diabetics. Stenotic lesions of the three major coronary arteries were more prevalent in diabetics than in non-diabetics (left anterior descending artery (LAD) 100 vs. 48%, p<0.01; right coronary artery (RCA) 77 vs. 39%, p<0.05; left circumflex artery (LCA) 69 vs. 24%, p<0.01) and in the same way diabetics showed higher narrowing percentage (LAD 74 +/- 30 vs. 30 +/- 36%, p<0.01; RCA 71 +/- 41 vs. 26 +/- 38, p<0.01; LCA 41 +/- 38 vs. 15 +/- 29, p<0.05). CONCLUSIONS: Our study demonstrates that although the uraemic milieu is a risk factor for IHD, diabetes increases the degree of atherosclerotic vascular damage independently of the other cardiovascular risk factors.

Relationship between diabetes mellitus and degree of coronary artery disease in uraemic patients investigated with coronary angiography.

Prevalence of cardiovascular disease is high in diabetic patients on renal replacement therapy (RRT); therefore we examined the role of diabetes mellitus on determining the degree of coronary artery stenosis. Twenty-five patients underwent coronary angiography, 12 were awaiting kidney transplantation and the examination was performed regardless of cardiac symptoms, 13 were affected by ischaemic heart disease (IHD). Diabetic and nondiabetic status together with the other risk factors for cardiovascular disease such as age, sex, length of time on RRT, smoking and elevated phosphorus levels history, clinical diagnosis of IHD, cerebrovascular and peripheral vascular disease, mean blood pressure, cholesterol, triglycerides, calcium, phosphate, albumin, haemoglobin, haematocrit and weekly dose of erythropoietin were derived from clinical records. All investigated parameters were matched in diabetic (group 1, n=10) and nondiabetic patients (group 2, n=15) and showed no differences. Clinical evidence of IHD was detected in 80% of patients in group 1 and 46% in group 2 and the percentage of patients on the renal transplant waiting list was not statistically different in the two groups (30 vs 60%). In 60% of patients in group 1 there were 3 or more stenotic lesions equal or greater than 75% of normal reference segment in the major coronary arteries, whilst in 53% in group 2 there were no haemodynamically significant narrowings. Narrowing percentage of the coronaries in group 1 and 2 were: right coronary artery 83 +/- 30 vs 32 +/- 41 (p<0.05), left anterior descending artery 80 +/- 25 vs 44 +/- 34 (p<0.05), left circumflex artery 46 +/- 37 vs 18 +/- 29 (p=0.05) respectively. Our study confirms that IHD is a clinical feature of uraemic diabetic patients and that diabetes is the main cardiovascular risk factor for determining the degree of coronary stenosis.

[Mesenteric ischemia in hemodialysis patients: case report and review of the literature]. / L'ischemia mesenterica negli emodializzati: descrizione di un caso e revisione della letteratura.

Mesenteric infarction is increasingly observed in uremic elderly patients with widespread atherosclerosis. A 77-year-old man on renal replacement therapy since June 1997 was admitted because of abdominal pain. The surgical diagnosis was massive intestinal infarction and the patient died a few hours later. A colonoscopy had been performed a few weeks before and a well-limited necrosis of the caecum mucosa had been detected. Hypotensive episodes were frequent during his hemodialysis sessions. In this work we discuss age, symptoms, laboratory investigations, risk factors and the evolution of case reports published during the last few years. Nephrologists should take into account the possibility of mesenteric ischemia in uremic patients with manifest arterio-occlusive disease, abdominal pain and leukocytosis, especially if hypotension is the major complication of the hemodialysis sessions.

[Coronary angiography in uraemic patients awaiting kidney transplantation]. / L'indagine coronarografica negli uremici in lista di attesa per trapianto renale.

BACKGROUND: Cardiovascular disease is the leading cause of morbidity and mortality in uraemia. Coronary angiography (CA) in patients awaiting kidney transplantation (PAKT) is still a matter of debate. In order to evaluate atherosclerotic coronary damage in PAKT, CAs of 12 PAKT were matched with those of 13 dialysis patients (P) affected by ischaemic heart disease IHD. METHODS: Age sex, length of time on renal replacement therapy, diabetes, smoking and hyperphosphataemia history, clinical diagnosis of IHD, cerebrovascular (CV) and peripheral vascular (PV) disease, mean blood pressure (BP), cholesterol, triglycerides, calcium, phosphate, albumin, haemoglobin, haematocrit and weekly dose of erythropoietin (EPO-dose) were derived from clinical records. RESULTS: PAKT were younger (48 9 vs 63 9 years, p < 0.01) and had higher diastolic BP values (86+/-10 vs 79+/-4 mmHg, p < 0.05) than IHD P. On the contrary all the other parameters investigated were not different in the two groups of P. Prevalence of IHD in PAKT was 16% while frequency of CV and VP disease were not different in the two groups. In 9 of IHD P stenotic lesions >/=75% of normal reference segment were diagnosed in 3 or more vessels whilst in PAKT there were atherosclerotic lesions in right coronary artery, left anterior descending artery and left circumflex artery in 41, 66 and 33% respectively. Narrowing percentage of the coronaries in PAKT and IHD P were: right coronary artery 27+/-42 vs 75+/-35, p < 0.05, left anterior descending artery 29+/-25 vs 86+/-15, p < 0.001, left circumflex artery 11 16 vs 47+/-38, p < 0.05 respectively. CONCLUSIONS: Our study shows that atherosclerotic coronary damage is present in PAKT and, although not hemodynamically significant, it could be an important risk factor for clinical expression of IHD. We conclude that CA should be performed in PAKT especially in those over 45 years.

Effect of dietary manipulation on the lipid abnormalities in patients with chronic renal failure.

Disorders of lipid metabolism could play an important role in mediating the progression of chronic renal disease toward uremia. The hypothesis of the nephrotoxicity of lipids has been considered in a large population of patients on long-term dietary protein restriction. In our experience, there is no evidence that lipid disorders may accelerate the progression of renal disease. Hypercholesterolemia and/or hypertriglyceridemia are probably only some of the many factors affecting the prognosis of renal disease. Dietary protein restriction seems to be effective in maintaining normal or only slightly elevated serum lipids in patients with early renal failure, even after years of dietary treatment, despite the natural progression of renal functional deterioration. Moreover, this dietary regimen has a favorable effect on lipid composition of erythrocyte membrane when compared with those of patients on a free diet.

Modification of serum and membrane lipid composition induced by diet in patients with chronic renal failure.

Disorders of lipid metabolism during chronic renal failure (CRF) play a crucial role in the pathogenesis of early cardiovascular complication of this syndrome. In addition, some experimental evidence suggests that hyperlipidemia may accelerate progression of renal disease. We have studied 65 patients with CRF (S-creatinine 1.5-9.0 mg/dl), 52.3% of whom were hypertensive. Patients were divided in 2 groups matched for age, sex and degree of renal failure: group 1 was kept for 36 +/- 8 months on a free diet; group 2 was kept for 39 +/- 6 months on a low-protein diet with an elevated polyunsaturated/saturated fatty acid (PUFA/SFA) ratio. We found significantly higher levels of triglycerides (TG) and lower levels of esterified cholesterol in high density lipoprotein (HDL-C) in group 1 than in group 2. Patients on the diet had a lower percentage of membrane SFA and a higher percentage of PUFA than patients on free diet. Only in group 1 a direct correlation between cholesterol/phospholipid (Chol/P) ratio and age was observed; in group 2, a negative correlation between levels of PUFA and TG and between linoleic/oleic (Lin/Ol) ratio and serum Chol was shown. S-creatinine levels were directly correlated with Chol/P ratio in group 1 and indirectly with Lin/Ol ratio and PUFA in group 2. These data show that a low-protein diet, containing an elevated PUFA/SFA ratio, is able to counteract lipid abnormalities in patients with CRF and the normalization of this pattern is associated with significant improvement of membrane lipid composition and, presumably, of "functional" activity of cell membranes with a better control of supposed "renal lipoprotein toxicity".

Effects of ketanserin administration on lipid metabolism and platelet aggregation in hypertensive patients.

Lowering blood pressure is not totally effective in preventing the atherosclerotic complications of systemic hypertension. In hypertensive patients both platelet hyperaggregation and dyslipidemia have been suggested as important risk factors. The effect of 8 weeks' treatment with ketanserin on blood pressure, serum lipid parameters (cholesterol, triglycerides, LDL, HDL-C, apolipoprotein A1 and B) and platelet aggregation, induced by collagen, ADP, arachidonic acid, was evaluated in 10 patients with essential hypertension. Ketanserin was effective in lowering blood pressure in all patients, 6 of whom became normotensive. Both CHOL and TG levels and APO B were significantly reduced, whereas HDL-C and APO A1 were significantly increased after treatment. These results might be attributed to the antagonistic activity of ketanserin on alpha-1 adrenoceptors with a consequent inhibition of phosphodiesterase. Platelet aggregation, after stimulation with collagen and arachidonic acid, was significantly reduced secondary to the inhibition of intraplatelet serotonin synthesis and release. These results suggest that keranserin is effective in reducing blood pressure and in achieving normal serum lipid pattern and platelet aggregation. Therefore, this drug might be helpful in controlling the main risk factors for cardiovascular damage.

Antihypertensive therapy with ketanserin: effects on central and renal hemodynamics, and microalbuminuria.

Ten patients with essential hypertension and normal renal function were treated with ketanserin (20-40 mg twice a day), administered for 8 weeks. In all patients, the changes in systemic and renal hemodynamics, and in urine albumin excretion, were assessed. Ketanserin monotherapy effectively lowered blood pressure in all patients. No change in cardiac output, pulse rate and stroke volume was observed; peripheral vascular resistance was significantly decreased. Plasma volume was unaltered. Renal plasma flow, glomerular filtration rate and filtration fraction were stable, with a slight but not significant reduction in renal vascular resistance. Urine albumin excretion remained unchanged. No relevant side effects were observed during the treatment period. In conclusion, our results confirm that ketanserin alone is an effective antihypertensive agent in patients with uncomplicated essential hypertension. The blood pressure lowering effect is mainly due to the systemic vasodilatation; renal hemodynamics and function are well preserved.