Location, variations, and predictors of epicardial fat mapping using multidetector computed tomography to assist epicardial ventricular tachycardia ablation.

BACKGROUND: A significant number of ventricular tachycardia circuits are located close to the epicardial surface and are amendable to epicardial ablation. Epicardial fat often interferes with substrate mapping and ablation, though little is known regarding the distribution of fat and its fluctuation with the cardiac cycle. METHODS: We studied 40 patients who underwent a 64-slice multidetector computed tomography in order to describe patterns of epicardial fat distribution, variation during cardiac cycle, and clinical predictors of epicardial fat. Multiplanar reconstructions were analyzed during systole and diastole in six cross-sections. Epicardial fat thickness was measured across multiple wall segments in each view. RESULTS: Epicardial fat was found to be thicker in areas overlying coronary vasculature (7.8 ± 2.6 mm vs 3.5 ± 0.9 mm, P = 0.001), along with the right ventricular wall (3.9 ± 0.8 mm vs 2.6 ± 0.6 mm, P = 0.001) and the ventricular base (6.1 ± 1.7 mm vs 4.6 ± 1.6 mm, P < 0.01). Epicardial fat thickness increased 27% during systole as compared to diastole (4.9 ± 2.7 mm vs 6.2 ± 3.0 mm, P = 0.04). Variation with cardiac cycle was most evident along the right ventricular wall (3.9 ± 0.8 mm vs 5.0 ± 1.3 mm, P = 0.001) and nonvascular areas (P = 0.001), especially at the ventricular base (3.7 ± 1.1 mm vs 5.3 ± 1.5 mm, P = 0.001). In multivariate logistic regression, we found that age >50 years (P = 0.031) and coronary artery disease (P = 0.023) were statistically correlated with epicardial fat >5-mm thickness and body mass index > 33 (P = 0.052) nearly so. CONCLUSIONS: Baseline epicardial fat thickness >5 mm is common in areas typically targeted during epicardial ablation and further increases during the cardiac cycle. Simple clinical characteristics can identify patients with >5 mm epicardial fat in which preprocedural computed tomography imaging and three-dimensional fat map reconstruction may facilitate epicardial ablation.

Pain Management for Persons Living With HIV Disease: Experience With Interprofessional Education in Nigeria.

CONTEXT: Pain management (PM) has not been routinely incorporated into HIV/AIDS care and treatment in resource-constrained settings. OBJECTIVES: We describe training for multidisciplinary teams tasked with integrating care management into HIV clinics to address pain for persons living with HIV in Nigeria. METHODS: Education on PM was provided to mixed-disciplinary teams including didactic and iterative sessions following home and hospital visits. Participants identified challenges and performed group problem solving. RESULTS: HIV trainers identified barriers to introducing PM reflecting views of the patient, providers, culture, and the health environment. Implementation strategies included (1) building upon existing relationships; (2) preliminary advocacy; (3) attention to staff needs; and (4) structured data review. CONCLUSION: Implementing PM in Nigerian HIV clinics requires recognition of cultural beliefs.

The effect of depressive symptoms and CD4 count on adherence to highly active antiretroviral therapy in sub-Saharan Africa.

BACKGROUND: Studies have identified several programmatic and nonprogrammatic indicators that affect adherence to highly active antiretroviral therapy (HAART). Depression has been shown to impact adherence to HAART. This cross-sectional analysis of data collected from Nigeria, Uganda, Zambia, and Tanzania in 2008 examined the relationship between levels of depressive symptoms, clinical progression, and adherence to HAART. METHODS: A multinational, multicenter, observational, retrospective cross-sectional evaluation of a population of focus comprised randomly selected patients on HAART. The dependent variable was adherence to HAART. The primary variable of interest to be assessed was patients' level of depressive symptom score. A multivariable logistic regression model was used to examine the relationship between explanatory variables and adherence to HAART. RESULTS: A total of 2344 patients were recruited for adherence survey. About 70% of the study sample reported having some level of depression. Logistic regression results show that patients who reported, respectively, low, moderate, and high levels of depressive symptoms are 35% (P < .001), 56% (P < .001), and 64% (P < .001) less likely to adhere to HAART than those who reported having no depressive symptoms. At multivariate analysis, adherence to HAART was independently associated with the levels of depressive symptoms, older age, CD4 count >200 cells/mm3, Truvada (tenofovir [TDF]/emtricitabine [FTC])-based regimens, good knowledge about HAART, and longer period on therapy. CONCLUSIONS: These results indicate that mental health and clinical parameters are significant factors in determining patients' adherence to their HAART, which need to be more aggressively addressed as a critical component of care and treatment support.

The effect of depressive symptoms and CD4 count on adherence to highly active antiretroviral therapy in sub-Saharan Africa.

BACKGROUND: Studies have identified several programmatic and nonprogrammatic indicators that affect adherence to highly active antiretroviral therapy (HAART). Depression has been shown to impact adherence to HAART. This cross-sectional analysis of data collected from Nigeria, Uganda, Zambia, and Tanzania in 2008 examined the relationship between levels of depressive symptoms, clinical progression, and adherence to HAART. METHODS: A multinational, multicenter, observational, retrospective cross-sectional evaluation of a population of focus comprised randomly selected patients on HAART. The dependent variable was adherence to HAART. The primary variable of interest to be assessed was patients' level of depressive symptom score. A multivariable logistic regression model was used to examine the relationship between explanatory variables and adherence to HAART. RESULTS: A total of 2344 patients were recruited for adherence survey. About 70% of the study sample reported having some level of depression. Logistic regression results show that patients who reported, respectively, low, moderate, and high levels of depressive symptoms are 35% (P < .001), 56% (P < .001), and 64% (P < .001) less likely to adhere to HAART than those who reported having no depressive symptoms. At multivariate analysis, adherence to HAART was independently associated with the levels of depressive symptoms, older age, CD4 count >200 cells/mm3, Truvada (tenofovir [TDF]/emtricitabine [FTC])-based regimens, good knowledge about HAART, and longer period on therapy. CONCLUSIONS: These results indicate that mental health and clinical parameters are significant factors in determining patients' adherence to their HAART, which need to be more aggressively addressed as a critical component of care and treatment support.

Treatment outcomes of recommended first-line antiretroviral regimens in resource-limited clinics.

BACKGROUND: Although used globally, little data exist on the efficacy of nevirapine (NVP) used in combination with tenofovir (TDF)/emtricitabine or lamivudine (XTC), and no large randomized prospective control trials exists comparing this combination with efavirenz (EFV)/TDF/(XTC). METHODS: As part of the AIDSRelief program, a retrospective review of patient medical chart information along with a cross-sectional viral load, and adherence measurement was conducted between 2004 and 2009. An on-treatment analysis excluded patients who died, transferred out of care, or were lost to follow-up. A switch of antiretrovirals for any reason was considered a failure in the intent-to-treat analysis. Patients with only clinically relevant reasons for switching such as toxicity, adverse effects, viral failure or clinical/immunological failure, lost to follow-up, and death were considered failures as part of the modified-intent-to-treat analysis. Step-wise multiple regression analysis was used to identify variables that were associated with viral suppression. RESULTS: A random sample of 3862 patients met criteria and were included in this analysis. In the on-treatment analysis, older age (P < 0.004) and baseline CD4 <100 cells per cubic millimeter (P < 0.021) were the most significant variables impacting viral load. Patients on TDF/XTC/EFV achieved higher rates of viral suppression compared with patients on TDF/XTC/NVP or azidothymidine (AZT)/lamivudine (3TC)/NVP. CONCLUSION: Our data show that patients on TDF/XTC/EFV had better outcomes than patients on TDF/XTC/NVP, AZT/3TC/EFV, or AZT/3TC/NVP. High rates of virologic suppression seen in patients on this regimen are consistent with previous studies and indicate the need to increase use of this regimen in HIV programs to promote sustainable viral suppression over time.