Antiretroviral therapy for HIV infection. Heartening successes mixed with continuing challenges

Probably nothing in the field of medicine has changed as rapidly over the last decade as antiretroviral (ARV) therapy for HIV infection. New insights into pathogenesis, new tests for measuring virus levels in plasma, and availability of powerful new drugs have combined to transform the care of persons with HIV infection into a field infused with real hope. However, ARV therapy remains complex, expensive, and not universally effective or available. This article focuses on a general approach to the use of ARV agents.     

Oral nutrition for the patient with HIV infection

In the era of highly active antiretroviral therapy, it is unclear what percentage of patients with HIV infection will develop nutritional issues, including weight loss, diarrheal illness and anorexia. The purpose of this article is to discuss nutritional concerns that can occur with HIV infection and potential treatment strategies. We have included 3 case studies identifying these issues and a nutritional assessment guideline. Nutrition interventions, exercise recommendations, and other alternative strategies to combat HIV associated weight loss is discussed.     

Physical medicine and its relationship to patient management

In this article, some general concerns for the use of modalities and procedures for the older person are given. Management of the geriatric patient requires knowledge, understanding, and patience; it requires a clinician and health care staff that care about older people. It requires a recognition of the dignity of age and the intrinsic worth of each individual as a human being. It requires hope and an ability to project a quality of life, regardless of the living condition. It requires kind words and a hands-on effort. It requires an appreciation of life and a high degree of ethical and moral concern.     

Physical therapy for a patient through six stages of amyotrophic lateral sclerosis

BACKGROUND AND PURPOSE: This case report describes the use of Sinaki and Mulder's approach to staging amyotrophic lateral sclerosis (ALS) and functional outcome measures in designing a treatment program for a 59-year-old woman with ALS. CASE DESCRIPTION AND OUTCOMES: As the patient progressed from stage I through stage VI, over 12 months, the physical therapy goals changed from optimizing remaining function, to maintaining functional mobility, and finally to maximizing quality of life. DISCUSSION: Disease staging and the use of functional outcome measures provide a framework for physical therapy evaluation and treatment of patients with ALS throughout the disease process. Physical therapists can assist patients with ALS through the provision of education, psychological support, rehabilitation programs, and recommendations for appropriate equipment and community resources.     

Neurologic problems of the lower extremity associated with HIV and AIDS

Lower extremity symptoms are caused by lesions at any level of the neuraxis, from cortex to muscle. HIV affects virtually every level of the nervous system, either directly or indirectly. The presence of pathology at multiple levels and by multiple processes further complicates the bedside diagnosis of a patient with AIDS and neurologic symptoms. Many neuropathies and other conditions that affect the lower extremities can be identified with careful history and physical examination, confirmed with limited testing, and can be treated successfully. Distal symmetric polyneuropathy is the most common lower extremity disorder, but it must be distinguished from similar-appearing neuropathies caused by medications, B12 deficiency, or vasculitis. Diffuse infiltrative lymphocytosis syndrome also causes a painful peripheral neuropathy that must be distinguished from distal symmetric polyneuropathy. Inflammatory demyelinating polyneuropathies are characterized by muscle weakness. They occur in early, asymptomatic HIV infection and respond to plasmapheresis or steroids. Mononeuropathies in patients with CD4 counts more than 200 often resolve on their own. Multiple mononeuropathies, which occur in patients with CD4 counts less than 50, are often associated with cytomegalovirus infection and may follow a rapidly progressive course unless treated promptly and aggressively. Progressive polyradiculopathy occurs late in the course of AIDS, is often caused by cytomegalovirus, is rapidly progressive, and generally is fatal unless recognized and treated promptly. Muscle weakness, myalgia, and fatigue are common in HIV and have multiple causes. Lower extremity spasticity may be caused by treatable etiologies such as spinal cord abscess, tumor, disc compression, B12 deficiency, or ischemia. Gait disturbances are common but nonspecific and may be caused by treatable neurologic disorders at any level of the neuraxis.     

Personal construct therapy for HIV seropositive patients.

Reports the application of constructivist assumptions of personal construct therapy to homosexual HIV seropositive patients as part of a psychotherapy research program. The underlying constructivist theory is briefly described, followed by the assumptions shared by personal construct therapists with other cognitive therapists, as well as their differences. A constructivist model of psychological reactions to being HIV seropositive is discussed, together with 3 cases that illustrate it. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Lower extremity static and dynamic relationships with rearfoot motion in gait

Twenty nonsymptomatic subjects were assessed while walking at a photoelectronically monitored place (2 +/- 0.1 m.s-1) using high speed cinematography (200 Hz) to record the rearfoot motion in the frontal plane, and electrogoniometry (100 Hz) to measure joint kinematics in the lower extremity. The foot type of the subjects was determined statically by using a podiascope and digitization techniques. The results demonstrated that no foot type variables contributed significantly to the variance in either rearfoot angle at foot strike or maximum rearfoot angle (p > 0.05). Regression equations were developed using kinematic variables: rearfoot angle at foot strike = 3.81 + (0.06*time to hip internal rotation) - (0.46*tibia internal rotation) + (0.14*plantarflexion); (R = 0.87, SE = 1.23 degrees); maximum rearfoot angle = 4.02 + (0.52*hip internal rotation) - (0.11*time to hip internal rotation); (R = 0.66, SE = 2.07 degrees). This study identifies hip joint movements as being the most significant contributors to prediction of rearfoot angles produced during walking.     

Polycythemia in a patient with HIV

A case of primary Nocardia otitidiscaviarum infection of a skin wound over an open fracture in a previously healthy adult who suffered multiple trauma in a car accident is reported. The organism was identified in cultures of pus specimens from the infected wound. The case demonstrated the difficulties of testing susceptibility of nocardiae in vitro and the necessity of prolonged antibiotic treatment. The prevalence of nocardial infections is underestimated, highlighting the need for adequate documentation of such infections and compilation of the information by public health authorities.     

Hospital management: quality and economy as management challenges for the physicians

As a consequence of the Gesundheitsstrukturgesetz (GSG-Health Structure Act) hospitals are called upon to organize the processes of medical, nursing care and administrative services more economically, without there being any reduction in either the social quality or the quality of the process or result of the task of caring for patients. Fulfilling the task of caring for patients professionally entails providing medical efficiency and economy (section 109 SGB V). The hospital management is called upon to harmonize supposedly conflicting objectives such as "increasing the quality whilst reducing the costs" through intelligent organization and leadership concepts. The maxims up to now were: "quality costs money", "innovations need time and money", "a shorter stay can only be guaranteed with additional capacity" etc. The new management paradigm demands: "higher quality and patient-effective innovations (e.g. minimally invasive procedures, out-patient operations) can be realized in a shorter time with a tendency towards falling costs" and "a shorter stay is achieved with less capacity through better organization". To guarantee these standards the doctor in particular is required to be a high performer because the responsibility for medical quality cannot be separated from the responsibility for economical work processes to achieve this quality. Every senior doctor when making his decision about the type and intensity of diagnosis and treatment automatically also makes a decision about executing these processes of medical services in a way which is tailored to suit the needs and economical requests. This management challenge for the doctor presents itself in several areas: --as a manager of the care cascade --as a manager of the services in the regional health network --as a manager of standardization in the field of logistics (e.g. steering of medical products like heart catheters from the point of manufacturing to the point of use) --as a manager who knows how to mobilize the problem-solving knowledge of his employees through delegation-orientated leadership; the concept of the management of wastefulness as an organization and management approach is particularly suitable for hospitals.     

Lower genital tract neoplasia in women with HIV infection

Women who are infected with human immunodeficiency virus (HIV) are at greater risk for the development of lower genital tract neoplasia than are HIV-negative women. Among HIV-positive women, those who are more severely immunosuppressed appear to be at higher risk for cervical intraepithelial neoplasia (CIN), also known as squamous intraepithelial lesions (SILs). Women who are HIV-positive also are more likely than HIV-negative women to have multifocal lower genital tract neoplasia. Cervical cancer is one of the most important acquired immune deficiency syndrome (AIDS)--related malignancies in women. Cancer and intraepithelial neoplasia of the lower genital tract can be persistent, progressive, recurrent, and difficult to treat in HIV-positive women. The most effective method for treating SILs has not been determined. Regular performance of Pap smears in HIV-positive women is of critical importance, as is careful examination of the entire lower genital tract. Also, women with high-grade intraepithelial or cervical cancer should be tested for HIV.     

Lower extremity purpura associated with new-onset autoimmune hepatitis: an unusual presentation

Adapalene is a new topical retinoid derived from naphthoic acid with a selective effect on the epidermis. It is indicated for treatment of acne vulgaris, alone or with other antiacneic topicals. It displays comedolytic and anti-inflammatory activities. The only frequent adverse event is a mild skin irritation during the first two weeks of treatment.     

Nutritional care of the patient with HIV/AIDS

Confluence in technologic advances in medical electronics, the availability of new intravenous pharmaceuticals, increasing sophistication of home care delivery systems and the economic motivations imposed by Diagnosis-Related Groups and capitated care payment mechanisms stimulated dramatic developments in intravenous delivery technologies, both for the hospital and the outpatient environment. Success in the use of these sophisticated drug delivery systems, however, depends on appropriate patient selection, optimal selection of a delivery alternative and careful patient monitoring for both desired therapeutic response, health delivery quality and patient safety.     

Accepting the challenges of pain management

Despite advances in the treatment of pain, studies reveal that hospitalized patients continue to suffer under-recognised and unrelieved pain. Several factors contribute to this problem including health-care professionals' lack of knowledge about pain and analgesia, the inadequate use of pain assessment techniques and incomplete charting of patients' reports of pain. This article describes these challenges which must be overcome if the situation is to improve. It outlines the potential value of systematic assessment and documentation of pain so that the patient's pain is acknowledged as a unique experience. This should enable the health professional to individualize his/her approach to pain management.     

Risk management with the suicidal patient: Lessons from case law.

Suicide continues to account for a comparatively large proportion of all lawsuits filed against mental health professionals. However, despite the prominence of suicide in mental health malpractice litigation, clinicians must resist resorting to defensive clinical practices in an attempt to shield themselves from potential lawsuits. By using accepted tenets of suicide management as a starting point, the author aims in this article to inform and educate practitioners about clinical malpractice from a legal, as well as a clinical, point of view. Hence, this article aims to demystify relevant case law for practitioners by offering informative, real life examples of how therapeutic practice is interpreted in the courtroom, as well as examples of how juries and judges typically view the treatment decisions clinicians routinely make regarding their suicidal patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)