Pediatric HIV infection and the primary care physician. Meeting unique needs

The number of HIV-infected children and adolescents is expected to increase during the next decade. Most of these patients are likely to receive nearly all of their healthcare from primary care physicians. Management must be multifaceted and consist of medical care for acute illnesses, routine pediatric care that includes immunizations, and social service intervention.     

Graduate education in primary care: the challenge

One can summarize the current status of calcium antagonists to treat heart failure as follows: Usually there is a favorable acute response to these drugs in heart failure patients but long-term effects in the patients treated with nifedipine, diltiazem, and verapamil have produced rather disappointing results. Thus, they should not be used routinely in heart failure patients. Their main problems were related to the negative inotropic effects of the drugs, the lack of reduction in ventricular filling pressure, and activation of the neurohumoral systems which have an adverse effect on cardiovascular performance, for example, renin-angiotensin. In contrast, the second-generation calcium antagonists have more selective vasodilating properties and fewer negative inotropic properties, which, I believe, justifies their use in selected heart failure patients. Unfortunately, there are no large randomized controlled long-term trials to evaluate morbidity and mortality in heart failure patients treated with these agents. One can rationalize that the symptomatic elderly patient with isolated diastolic dysfunction can be treated effectively with calcium antagonists but, once again, there are no major trials evaluating any drug in the management of patients with isolated diastolic function not due to hypertrophic cardiomyopathy. Rationale for using calcium antagonists could be best supported in patients with active ischemic heart disease and symptoms of heart failure. In this instance the coronary vasodilator effects may relieve myocardial ischemia and, by that mechanism, improve myocardial systolic and diastolic function.     

Primary care of HIV infection

Four cases illustrate some of the issues involved in treating HIV-infected patients in a primary care setting. Primary care physicians are hard-pressed to achieve the same results as infectious disease specialists, yet are increasingly responsible for performing the initial tests, choosing the therapeutic regimen, ensuring the patient's compliance with the regimen, and monitoring the results.     

The profile of HIV infection in women: a challenge to the profession

Human Immunodeficiency Virus (HIV) has become a leading cause of morbidity and mortality among women and children in the United States. As advances are made in the area of diagnosis and treatment of HIV infection, strategies must be developed to support the psychosocial needs of women with HIV disease. The diagnosis of HIV infection in women and their children presents a unique array of complicated social, emotional and medical consequences. Care must be provided in a holistic manner with special emphasis on the needs of women within a systemic context.     

Pneumocystis carinii pneumonia in HIV primary infection]

We report a case of osteoid osteoma as a cause of hip pain in a young athlete. Excision of the lesion resulted in complete relief of the symptoms.     

Biological and virologic characteristics of primary HIV infection

BACKGROUND: The clinical events surrounding acute HIV-1 infection have been well described, but little is known about whether the virologic course of acute HIV-1 infection influences the subsequent progression of disease. OBJECTIVE: To define the virologic natural history of acute and very early HIV infection. DESIGN: Prospective, longitudinal cohort study. SETTING: University of Washington Research Clinic PARTICIPANTS: 74 adults enrolled soon after acquisition of HIV (mean, 69 days). MEASUREMENTS: Plasma HIV-1 RNA levels; quantitative cell cultures; CD4 cell counts; and detailed clinical assessments done at study entry, biweekly for 1 month, monthly for 2 months, and quarterly thereafter. RESULTS: In the first 30 days after acquisition of HIV, HIV-1 RNA levels varied greatly among participants (range, 27,200 to 1.6 x 10(6) copies per mL of plasma). Levels of HIV-1 RNA decreased by a mean of 6.5% per week for the first 120 days and then increased by a mean of 0.15% per week. CD4 cell counts decreased by a mean of 5.2 cells/mm3 per week for the first 160 days and by a mean of 1.9 cells/mm3 per week thereafter (P < 0.01). Disease progressed faster in participants who sought medical care for their acute seroconversion syndrome (P = 0.01) and those who had high plasma HIV-1 RNA levels 120 to 365 days after acquisition (P < 0.01). Peak levels in the first 120 days were not predictive of disease progression. CONCLUSIONS: The variability in viral RNA levels associated with acute HIV-1 infection is greater than previously appreciated. Within 120 days of acquisition, plasma HIV RNA levels rapidly decrease to an inflection point, after which they gradually increase. Virus-host interactions soon after acquisition seem to have a major influence on the long-term outcome of HIV-1 disease.     

Attitude and structural barriers detected in primary care physicians towards treating patients with HIV/AIDS infection

OBJECTIVES: To identify attitudes, knowledge and self-perceived risks among doctors in the Este-Oriente District of Sevilla concerning HIV/AIDS infection; to detect attitude problems and structural barriers affecting doctors' predisposition towards patients with HIV/AIDS infection. DESIGN: A cross sectional study using a self-administered questionnaire. SETTING: Este-Oriente Primary Care district, Sevilla. PARTICIPANTS: Permanent and provisional doctors and paediatricians working in the district during the survey. MEASUREMENTS AND RESULTS: Reply rate was 86% (n = 111). Most doctors (85%) had treated one or more patients with HIV. 91% thought they had to treat these persons. However, 21% would not work with them, if they had the choice. CONCLUSIONS: Attitudes of doctors and paediatricians in the Este-Oriente district of Sevilla towards HIV/AIDS patients can be qualified as positive. Most doctors need to extend their knowledge of this disease. The perception of risk of contagion is high and higher than the real risk. Important attitude and structural barriers to care provision were detected: intervention strategies were proposed by the doctors and paediatricians of this district.     

Central nervous system lesions in the early stages of HIV infection]

Early HIV-1 invasion of the central nervous system has been demonstrated by many cerebrospinal fluid studies; however, most HIV-1 carriers remain neurologically unimpaired during the so-called "asymptomatic" period lasting from seroconversion to symptomatic AIDS. Therefore, very few neuropathological studies have been conducted in the early pre-AIDS stages, and the natural history of central nervous system changes in HIV-1 infection remains poorly understood. Examination of brains of asymptomatic HIV-1 positive individuals who died accidentally and of rare cases with acute fatal encephalopathy revealing HIV infection, and comparison with experimental simian immunodeficiency virus and feline immunodeficiency virus infections suggest that, invasion of the CNS by HIV-1 occurs at the time of primary infection and induces an immunological process in the central nervous system. This includes an inflammatory T-cell reaction with vasculitis and leptomeningitis, and immune activation of brain parenchyma with increased number of microglial cells, upregulation of major histocompatibility complex class II antigens and local production of cytokines. Myelin pallor and gliosis of the white matter are usually found and are likely to be the consequence of opening of the blood-brain barrier due to vasculitis; direct damage to oligodendrocytes by cytokines may also be involved. These white matter changes may explain, at least partly, the early cerebral atrophy observed, by magnetic resonance imaging, in asymptomatic HIV-1 carriers. In contrast, cortical damage seems to be a late event in the course of HIV-1 infection. There is no significant neuronal loss at the early stages of the disease, no accompanying increase in glial fibrillary acid protein staining in the cortex, and only exceptional neuronal apoptosis. Although HIV-1 proviral DNA may be demonstrated in a number of brains, viral replication remains very low during the asymptomatic stage of HIV-1 infection. This makes it likely that, although opening of the blood brain barrier may facilitate viral entry into the brain, specific immune responses including both neutralising antibodies and cytotoxic T-lymphocytes, continuously inhibit viral replication at this stage.     

Lymphocytic alveolitis after primary HIV infection with CMV coinfection

Herein is a report of an adult case of primary HIV infection with cytomegalovirus coinfection causing cough, fever, and lymphocytic alveolitis. Primary HIV infection has not been previously reported as a cause of lymphocytic alveolitis.     

False positive results: a challenge for psychiatric screening in primary care

OBJECTIVE: The goal of this study was to characterize primary care patients with false positive results on screens for mental disorders. METHOD: A sample of 1,001 primary care patients completed self-administered screens and structured interviews for DSM-IV diagnoses. RESULTS: A substantial proportion of the patients with false positive screen results for at least one diagnosis met the diagnostic criteria for other psychiatric disorders. They also had significantly greater functional impairment and higher rates of recent use of mental health services than the subjects with true negative results on the screens. CONCLUSIONS: Although the positive predictive values of screens for specific mental disorders are in line with those of other medical screens, false positive results are not uncommon. This may be due in part to the sensitivity of brief screening instruments to nonspecific symptoms. The results suggest that as with other screens used in primary care, patients with false positive results on screens for mental disorders should receive clinical attention.     

Meeting the challenge of diabetic blindness in the 90''s

We developed and characterized a model of global forebrain ischaemia in rats, permitting control of CBF at any desired ischaemic level with minimum surgery and without anticoagulation. Both common carotid arteries are occluded temporarily and systemic arterial pressure is lowered by pooling venous blood by lower body negative pressure with a cheap suction device. By measuring rCBF continuously (laser-Doppler-flowmetry) and regulating systemic arterial pressure, the model was used to automatically control cortical rCBF at predetermined ischaemic levels at 50, 30, 15, and 5% of normal rCBF (n = 5). When both common carotid arteries were occluded and systemic arterial pressure was lowered to 55 mmHg with hypobaric hypotension (n = 5), cortical CBF always fell to less than 5% of normal rCBF (n = 5). Prompt recirculation was achieved after reopening of the carotid arteries and return to normobaric body pressure. Hypobaric hypotension with bilateral common carotid occlusion requires only carotid surgery and measurement of systemic arterial pressure; it produces global forebrain ischaemia without anticoagulation as a true step function type insult. If rCBF is measured continuously, the model can be used to control ischaemic CBF to predetermined values.