A case of systemic cryptococcal disease in HIV infection.

Globally, Cryptococcosis is the most common invasive mycosis in HIV disease. Incidence rates vary widely by geographical region and resource availability and reportedly range from 0.04 to 12% per year (1). Sub-Saharan Africa accounts for the greatest burden with a median incidence of 3.2% per year (1). Since the advent of widespread use of antiretroviral therapy (ART), incidence rates of opportunistic infections have been significantly declining (2).

What are the benefits and barriers of communicating parental HIV status to seronegative children and the implications for Jamaica? A narrative review of the literature in low/middle income countries.

OBJECTIVE: To examine the benefits/barriers for HIV positive parents of communicating their status to seronegative children in low/middle income countries in order to inform policy and practice in Jamaica. METHODS: The authors carried out a systematic search of published literature on parental disclosure in low/middle income countries written in the English language between January 1991 and September 2012, identified from databases: Academic Search Complete, CINAHL, EBSCOhostEJS, Gender Studies Database, Health Policy Reference Centre, MEDLINE (includes the West Indian Medical Journal), PsycARTICLES , PsycINFO , SocINDEX, AMED, Global Health, Embase, Social Policy and Practice, Maternity and Infant Care. The authors also refer to articles on parental disclosure in high income countries which appeared in peer-reviewed journals and conducted a local search in Jamaica for articles on HIV disclosure in the Caribbean region. RESULTS: Global estimates of parental disclosure rates were 20-97% in high income countries and 11-44% in resource constrained countries. Mean age of children at disclosure was age 10-18 years. Mothers were more likely to disclose to older children, female children, and when they had strong support networks. Barriers included fear of stigma/discrimination, not knowing how to tell the child, fear of the child disclosing to others and believing a child was too young to cope. Of the 16 articles identified which met the search criteria, 10 studies and three reviews noted positive benefits of disclosure on parental health and the parent-child relationship. CONCLUSION: Significant differences in attitudes and rates of maternal disclosure in low/middle income countries compared to high income countries reflect the impact of cultural, structural, economic and social factors and highlight the need for culturally-specific research. Implications for policy and practice in Jamaica are discussed.

A review of the HIV-infected homeless sub-population at the Centre for HIV/AIDS Research, Education and Services, Department of Medicine, University Hospital of the West Indies.

OBJECTIVE: The twin epidemics of HIV and homelessness present several challenging aspects to the development of programmes for the provision of treatment and care. This paper describes the characteristics of this population being managed by a collaborative effort between the Centre for HIV/AIDS Research, Education and Services, Department of Medicine, University Hospital of the West Indies and the National Council on Drug Abuse. SUBJECTS AND METHODS: A retrospective descriptive study was conducted via review of patients'medical files. Demographic and clinical data of the HIV-infected homeless population were summarized, highlighting issues related to the provision of care, rates of antiretroviral therapy (ART) uptake and subsequent adherence to treatment and known factors associated with HIV transmission. RESULTS: A total of 12 cases were included in the analysis. There was an average age of 38.0 years (IQR 32.5-49.25) with the majority being female, nine (75.0%). Late stage diagnosis was a common feature. The majority of cases were eligible for ART on first contact, with CD4 counts on average being 284.4 (95% CI 10.9.0, 459.8). Significant risk factors for HIV transmission were also identified as all cases reported being sexual active with limited condom use reported and high reported numbers of lifetime partners, 30 (IQR 25.0-100.0). Other factors identified include eight (66.6%) cases reporting sexually transmitted infection (STI) symptoms, 10 (83.3%) reporting substance abuse and nine (75.0%) reporting sex work. CONCLUSION: The implementation of combination interventions providing a comprehensive package of services that address the multitude of issues facing the HIV-infected homeless population is required in order to appropriately manage this population.

Depression among persons attending a HIV/AIDS outpatient clinic in Kingston, Jamaica.

OBJECTIVES: To determine the prevalence of depression among persons attending a HIV/AIDS clinic in Kingston, Jamaica, and to explore the possible role of patient-specific clinical and social issues as intermediary factors in the relationship between HIV/AIDS and depression. SUBJECTS AND METHODS: Over a three-month period, all eligible and consenting patients from a HIV/ AIDS clinic in Kingston, Jamaica, were invited to participate in the study. They were interviewed using the Patient Health Questionnaire (PHQ-9), an instrument validated for the detection of depression in primary care settings. Clinical and socio-demographic data were retrieved for all participating patients from a pre-existing clinic database. Depression prevalence rates were calculated and the association between depression and age, gender, antiretroviral treatment, CD4 count, living arrangement, marital status and major stressors explored. RESULTS: Sixty-three patients participated in the study and 43% (n = 36) of them were depressed. No significant differences in depression rates were found with respect to any of the sociodemographic or clinicalfactors explored (p > 0.05). CONCLUSION: The relatively high prevalence of depression among attendees at the HIV/AIDS clinic underscores the need for depression screening in these patients.

An analysis of three opportunistic infections in an outpatient HIV clinic in Jamaica.

OBJECTIVES: To determine the occurrence of opportunistic infection (OI) in HIV-positive patients and to identify any risk factors which may be associated with such. METHODS: A cross-sectional study of all patients attending the HIV out-patient clinic was conducted. Their hospital notes were examined between January 1 and December 31, 2007 inclusive, to identify any occurrence of opportunistic infection. In addition, the patient list was also cross-referenced with all patients hospitalized on the medical wards during the same time period. Clinical and demographic data were collected for all participants. The occurrence of opportunistic infections and the variables of age, gender CD4 counts and viral loads: (first ever last in 2007 and at diagnosis of OI [or within six months]), the use of primary and secondary prophylaxis, the discontinuation of prophylactic regimens and the HAART regime at diagnosis of an OI and the diagnostic and treatment protocols of these infections were calculated. RESULTS: Six hundred and three patients participated in the study and 4.7% (n = 28) were found to have experienced at least one opportunistic infection in 2007. Significant associations were found between first and last CD4 cell count, viral load in 2007, year of entry into the clinic and death (p < 0.05). CONCLUSIONS: Opportunistic infections continue to cause significant morbidity and mortality in the HIV-patient population in this study. Earlier entry to treatment facilities and the use of HAART and appropriate prophylaxis can reduce this impact and lead to improved quality of life for HIV-positive individuals.

Response to first line HAART using CD4 cell counts experience in a university hospital in Kingston.

OBJECTIVES: To assess the extent to which the current practice for first line therapy concurs with the recommended guidelines and to examine the response of treatment naïve patients to first line Highly Active Antiretroviral Therapy (HAART) at the University Hospital of the West Indies, using CD4 cell counts. METHODS: Over a three-month period, a cross-sectional study design was instituted and data were collected on all patients on HAARTat the University Hospital of the West Indies (UHWI) outpatient HIV clinic. Information was collected by reviewing patient medical records using data collection sheets. The data obtained from the medical records included: age, gender date of diagnosis of HIV date at which HAART was commenced, CD4 cell counts prior to the commencement of antiretrovirals, the initial HAART regimes and subsequent CD4 cell counts. RESULTS: A total of 165 persons who met the criteria of being on HAART therapy were enrolled in the study The average time span between diagnosis of HIV and commencement of antiretroviral therapy was 1.92 years and the range for this was 0 to 12.29 years. The average CD4 count prior to initiation of HAART was 186 cells/mm3. The most common regime used at the UHWI for first line therapy was combivir and efavirenz, n = 78 (47.3%), followed by combivir and nevirapine, n = 29 (17.6%). The average difference between the initial CD4 count prior to the initiation of HAART and first repeated CD4 count was 102 cells/mm3. The mean time between the first and repeated CD4 cell counts was 376 days. CONCLUSION: The recommended guidelines were adhered to for the majority of patients initiated on antiretrovirals at the UHWI. The treatment outcomes achieved at the UHWI were similar to those achieved in developed countries. This gives substantial evidence in support of international efforts to make antiretroviral therapy available in developing countries.

Disclosure of HIV status among HIV clinic attendees in Jamaica.

OBJECTIVE: This study aimed to examine factors related to disclosure of HIV serostatus among clinic attendees in an outpatient HIV clinic at the University Hospital of the West Indies (UHWI). METHODS: This was a cross-sectional survey of 107 attendees to a HIV clinic at the University Hospital of the West Indies. Participants were selected on a convenience basis. The instrument was developed for this study and covered socio-demographic data and self-report of disclosure and other variables related to HIV experience such as perceptions of family support. Data were analysed using nonparametric tests. RESULTS: Findings demonstrate a 49% disclosure rate among males and 60% among females. The results further indicate that age, sexual orientation, mode of transmission, and perception of family support were significantly associated with disclosure. Age and perception of family support were found to be significantly associated with consistent condom use. Age and perception of family support were the factors demonstrating the most significant correlations with age being significantly associated with disclosure to partner. Perception of family support was significantly associated with disclosure to family. CONCLUSION: Findings from this study demonstrate a low disclosure rate among HIV clinic attendees. Given that disclosure of HIV serostatus is critical in the control of the spread of HIV this report highlights the need for the development of prevention interventions focussed on de-stigmatization for both infected and non-infected persons.

Sociodemographics and clinical presentation of HIV in Jamaica over 20 years. A comparative analysis of surveillance data.

OBJECTIVE: To delineate changes in the epidemiology of HIV including morbidity and mortality patterns based on three key time points in Jamaica's HIV response. METHOD: Surveillance data from Jamaica's HIV/AIDS Tracking system (HATS) were analysed and distribution of cases by age, gender sexual practice, risk factors and clinical features were determined for three time periods (1988-1994: formal establishment of HIV surveillance at the national level, 1995-2003: introduction of HAART globally; 2004-June 2008: introduction of HAART and HIV rapid testing in Jamaica). Factors that predicted late stage diagnosis (AIDS or AIDS death) were also determined RESULTS: 22 603 persons with HIV were reported to the Ministry of Health, Jamaica, between 1988 and June 2008. Between the first and last time blocks, the modal age category remained constant (25-49 years) and the proportion of women reported with HIV non-AIDS increased from 32.5% to 61.4% (p < 0.001). However the male:female ratio for persons reported with AIDS remained at 1.3:1 between 1995 and 2008. Although heterosexual transmission was the most frequent mode of transmission in each time period, sexual behaviour was consistently under-reported (4769 persons or 21% of all cases ever reported). Late stage diagnosis (AIDS or AIDS death) decreased significantly between the first and last time blocks (16% decline, p < 0.0001) with men, older persons and persons with unknown risk history being more likely to be diagnosed at AIDS or AIDS death. CONCLUSION: HIV testing and treatment programmes have improved timely diagnosis and reduced morbidity associated with HIV infection in Jamaica. However new strategies must be developed to target men and older persons who are often diagnosed at a late stage of disease. Surveillance systems must be strengthened to improve understanding of persons reported with unknown risk behaviours and unknown sexual practices.

Long-term effects of cancer treatment and consequences of cure: cancer survivors enjoy quality of life similar to their neighbours.

To assess the long-term effects of cancer treatment and consequences of cure, 102 index cancer cases were compared with 95 neighbourhood controls of similar age and sex and with 78 cardiac controls. The quality of life experienced by these three groups was examined using multiple instruments with proven psychometric properties. All the major quality of life domains (physical, psychological and social) were covered. The findings revealed that the index cases were similar to their neighbours in areas of subjective well-being. However, the index cases exhibited more sexual dysfunction, were more conscientious, determined and emotionally disciplined, and applied the defence mechanisms of displacement and reaction formation more often than the neighbourhood controls. The cardiac controls were older, more anxious, more conventional/less imaginative and used suppression as a defence mechanism to a greater degree than the index cases. In conclusion, young adult cancer survivors enjoy a quality of life similar to their neighbours, whereas coronary bypass survivors adjust less well psychosocially.

A study of the efficacy of the bradykinin antagonist, NPC 567, in rhinovirus infections in human volunteers.

In a double-blind placebo controlled trial intranasal NPC 567, a bradykinin antagonist, failed to alleviate the symptoms of experimental rhinovirus colds. Indeed, there was evidence that the drug enhanced the symptoms although no irritant effect was detected on the uninfected nasal mucosa.

A note on the failure of CGP 19835 A (MTP-PE) to influence the course of influenza A2 infection in human volunteers.

A single dose of the immunomodulator CGP A (MTP-PE) given intranasally to human volunteers 24 h prior to challenge with influenza A2 virus failed to protect against infection or ameriolate any subsequent illness.

The efficacy of intranasal interferon alpha-2a in respiratory syncytial virus infection in volunteers.

In a double-blind, placebo-controlled study, self-administered intranasal interferon alpha-2a or placebo was given both before and after challenge with respiratory syncytial virus. The incidence of colds and the severity of signs and symptoms were reduced in those receiving interferon alpha-2a as compared with those given placebo. In a further double-blind, placebo-controlled study, self-administered interferon alpha-2a or placebo was given only to those volunteers who developed colds following challenge with respiratory syncytial virus. There was no evidence that interferon alpha-2a reduced the severity of the signs and symptoms or shortened the duration of the illness. The similarity of these results to the effect of interferon alpha-2a in rhinovirus infections in volunteers is discussed.

Failure to demonstrate synergy between interferon-alpha and a synthetic antiviral, enviroxime, in rhinovirus infections in volunteers.

Marked synergy between the antirhinoviral effect of rHuIFN alpha and enviroxime has been observed in vitro but an attempt to demonstrate it in volunteers was unsuccessful. The sub-optimal intranasal dose of rHuIFN alpha (0.18 Mu four times daily for 4 1/4 days) used prophylactically in the trial did reduce the severity of colds induced by RV9 and 14, but the difference did not reach statistical significance and was not enhanced by the administration of enviroxime (0.28 mg six times daily for six days). The main reason for failure is thought to be the rapid removal of enviroxime from the nose when given intranasally.

A non-pathogenic vibrio for the routine quality control of TCBS cholera medium.

A non-pathogenic "indicator" organism to relapse Vibrio cholerae in the routine quality control of TCBS medium was sought among a large collection of freeze-dried vibrios isolated mostly from environmental sources. One strain, which was consistently more sensitive to inhibition of growth on TCBS medium that strains of V. cholerae and V. parahaemolyticus, is recommended for this purpose. It has been deposited with, and is available from, the National Collection of Type Cultures as NCTC 11218.

A combined casein-free-nicotinamide diet prevents diabetes in the NOD mouse with minimum insulitis.

We have previously shown that diabetes in the NOD mouse can be prevented if mice are placed from weaning on an infant formula diet in which the protein source is replaced with casein hydrolysate (Pregestimil) or soy protein (Prosobee), or if 1% nicotinamide is given in the drinking water. Nicotinamide somewhat suppresses insulitis but the hydrolysed casein formula does not. In this study, Prosobee was given concurrently with oral nicotinamide from weaning and their effects on the development of insulitis and diabetes measured. These effects were also assessed in mice given Prosobee alone from conception (day -20) or from weaning. Unlike the earlier experiments, a marked suppression of insulitis was observed when the diets and nicotinamide were given concurrently (mean insulitis scores +95% confidence intervals (back transformed): day 40 = 0.4% [0.03, 1.17] vs. 12.5% [2.52, 28.40] and at day 90 = 8.8% [3.65, 15.68] vs. 48.1% [33.89, 62.49], P = 0.0001). A similar suppression was observed on day 90 with Pregestimil combined with nicotinamide 7.3% [3.88, 11.70] vs. 43.8% [32.59, 55.35] (P = 0.0001). Qualitatively, introduction of Prosobee from conception appeared to elicit a greater degree of suppression of insulitis than when introduced from day 21. Insulitis lesions were examined immunohistochemically for CD4, CD8 and MAC-1 cells. The proportion of these cells was not different for any regime despite the great differences in total number of inflammatory cells in and around the islets of mice fed the combined diet. All the three dietary treatments (Prosobee from day -20, Prosobee from day 21, Prosobee+nicotinamide from day 21) resulted in substantial protection from diabetes in mice followed until 250 days. We conclude that the complete prevention of diabetes in the NOD mouse fed a casein-free diet together with nicotinamide is accompanied by marked inhibition of insulitis, which is not seen when either dietary agent is introduced alone. The somewhat greater suppression of insulitis in mice given the soy diet from conception compared to those fed from day 21 may indicate that even maternal diet during gestation may influence diabetes outcome in the offspring.

Predictors of outcome in the treatment of chronic "psychogenic" pain with amitriptyline and brief psychotherapy.

Baseline measures associated with outcome are described for amitriptyline and brief psychotherapy used in the outpatient treatment of chronic "psychogenic" pain. The results delineate patient profiles associated with suitability for these treatments. These may serve as guidelines for choice in the treatment of heterogeneous pain clinic patients.

Menstrual irregularity and stress fractures in collegiate female distance runners.

From 240 questionnaires, we investigated the prevalence of stress fractures in competitive collegiate female long distance runners and its relationship to menstrual history. The runners were divided into three groups according to their menstrual history: very irregular 69/240 (0 to 5 menses/year), irregular 51/240 (6 to 9 menses/year), and regular 120/240 (10 to 13 menses/year). Stress fractures occurred in 49% of the very irregular runners, 39% of the irregular runners, and 29% of the regular runners. The majority of the stress fractures occurred in the tibia. Runners who had never used oral contraceptives were over twice as likely to have had a stress fracture when compared with runners who had used oral contraceptives for more than 1 year. These data suggest that female distance runners who have a history of irregular or absent menses and who have never used oral contraceptives may be at an increased risk for developing a stress fracture. When amenorrheal runners were separated from the very irregular group, an alarming trend was noted in eating behavior disorders. Forty-seven percent of the amenorrheal group, 20% of the one to five menses/year group, 10% of the irregular group, and 7% of the regular group admitted to an eating behavior disorder.

Effects of experimentally induced colds on aspects of memory.

Four experiments were carried out to investigate the effects of experimentally-induced colds on various aspects of memory of 27, 47, 39, and 30 adults. Free recall, digit span, and retrieval from semantic memory were unaffected by having a cold. Immediate recognition of important information from a story was impaired in subjects with colds, which suggests they were less able to follow the theme of the story. In contrast to this, volunteers with colds had better recognition of information from a story learned prior to the virus challenge.

Prevalence of Chronic Kidney Disease among Patients Attending an HIV Outpatient Clinic in Kingston, Jamaica / Prevalencia de la enfermedad renal crónica entre los pacientes que asisten a una clínica ambulatoria de VIH en Kingston, Jamaica

ABSTRACT The medical records of 983 patients diagnosed with the human immunodeficiency virus (HIV) were reviewed, 501 of whom were female and 482 were male. The mean age was 42.1 years, the mean number of years since diagnosis of HIV was 7.4, and the average duration of highly active antiretroviral therapy (HAART) was 51.7 months. The mean CD4 count at diagnosis was 268.5 cells/μL, but the most recent CD4 count was 461 cells/μL, and 85.8% of the patients were on HAART. The mean CD4 count was lower in those with a glomerular filtration rate (GFR) of < 60 ml/minute/1.73m2 compared to those patients with only proteinuria and a GFR of > 60 ml/minute/1.73m2. In the sample population, 76.9% of the patients had chronic kidney disease stage 3, 7.7% were in stage 4 and 15.4% in stage 5. There were 3.1% of patients with persistent proteinuria. Hypertension and diabetes mellitus were co-morbidities.

RESUMEN Se revisaron las historias clínicas de 983 pacientes diagnosticados con el virus de la inmunodeficiencia humana (VIH), 501 de los cuales eran mujeres, y 482 hombres. La edad promedio fue de 42.1 años, el número promedio de años a partir del diagnóstico de VIH fue 7.4, y la duración promedio de la terapia antirretroviral altamente activa (TARAA) fue de 51.7 meses. El conteo de CD4 promedio en el momento del diagnóstico fue de 268.5 células/μl pero el más reciente conteo de CD4 fue de 461 células/μl y el 85.8% de los pacientes se encontraban bajo terapia TARAA. El conteo de CD4 promedio fue menor en aquellos pacientes con una tasa de filtrado glomerular (TFG) de < 60 ml/minuto/1.73 m2, en comparación con los pacientes que tenían sólo proteinuria y una TFG de > 60 ml/minute/1.73 m2. En la población de la muestra, el 76.9% de los pacientes tenía enfermedad renal crónica en etapa 3, el 7.7% estaba en la etapa 4, y el 15.4% en la etapa 5. Había 3.1% de pacientes con proteinuria persistente. La hipertensión y la diabetes mellitus fueron comorbilidades.