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HIV infection stage at diagnosis and epidemiological features of late presentation
V Rodríguez,C Freuler,C Ezcurra,V Sanchez
Journal of the International AIDS Society , 2012, DOI: 10.7448/ias.15.6.18159
Abstract: Late presentation of HIV-infected individuals is gaining attention because of the negative impact on the patient and the society at a whole. In January 2011 the European Late Presenter Consensus working group published a consensus definition of “late presentation” and asked researchers to implement it. Objective: to identify presentation stage of HIV-infected individuals at diagnosis at the German Hospital in Buenos Aires, Argentina, and describe epidemiological features of them. The German Hospital is an acute care community hospital that assists around 600 000 out-patient consultations per year. We examine the clinical reports of all our HIV patients, diagnosed 1984–2011, and grouped them as “late” or “not late” presentation according their status following the consensus definition criteria. We also looked for data, such as age, sex and year of diagnosis, that could differ between the groups. We reviewed 284 clinical records, 7 of which were excluded because of lack of data; 105 belonged to last century records. Median age for 1984–1999 group: 32 (16–73), for 2000–2010 group: 40 (180–78). 77% of the first group were men, and 88% of the second one.In 55,5% of the 1984–1999 group diagnosis was due to an opportunistic infection, whereas the same applied to only 32,8% of the 2000–2010 group. In both groups there were a high proportion of male, due to the population profile of our hospital. The most frequent reason for testing was screening, but there is still a high number of late diagnosis and OI as first sign of the infection. Younger people are more aware of the need of testing. Female have the advantage of being tested when planning or becoming pregnant. We could not find statistical differences comparing data of both centuries. Forty percent of infections were diagnosed in a “not late” stage, but that was more evident in younger people. People in general and physicians in particular should be more aware of HIV in elderly people.
Determinants of late disease-stage presentation at diagnosis of HIV infection in Venezuela: A case-case comparison
Maeva A Bonjour, Morelba Montagne, Martha Zambrano, Gloria Molina, Catherine Lippuner, Francis G Wadskier, Milvida Castrillo, Renzo N Incani, Adriana Tami
AIDS Research and Therapy , 2008, DOI: 10.1186/1742-6405-5-6
Abstract: Of 225 subjects, 91 (40%) were defined as late presenters. A similar proportion (51/129) was obtained in the interviewed sub-sample. Older age (>30 years), male heterosexuality, lower socio-economic status, perceiving ones partner to be faithful and living ≥ 25 km from the CAI were positively associated with late diagnosis in a multivariate model. Females were less likely to present late than heterosexual males (odds ratio = 0.23, P = 0.06). The main barriers to HIV testing were low knowledge of HIV/AIDS, lack of awareness of the free HIV program, lack of perceived risk of HIV-infection, fear for HIV-related stigma, fear for lack of confidentiality at testing site and logistic barriers.Despite the free Venezuelan HIV Program, poverty and barriers related to lack of knowledge and awareness of both HIV and the Program itself were important determinants in late presentation at HIV diagnosis. This study also indicates that women; heterosexual, bisexual and homosexual men might have different pathways to testing and different factors related to late presentation in each subgroup. Efforts must be directed to i) increase awareness of HIV/AIDS and the Program and ii) the identification of specific factors associated with delay in HIV diagnosis per subgroup, to help develop targeted public health interventions improving early diagnosis and prognosis of people living with HIV/AIDS in Venezuela and elsewhere.With an estimated 110,000 people living with Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) (PLWHA) in 2005, Venezuela is among the countries with the highest HIV prevalence (0.7% in adults) in Latin America [1]. The ratio men to women gradually changed from 19:1 in the eighties to 2:1 in 2004 [2]. As in the rest of Latin America, HIV is mostly spread through sexual transmission, accounting for 90% of all reported HIV-infections between 1982 and 1999 [3]. Of the reported sexual transmissions of HIV 65% in that period involved men who had sex
Risk Factors for Late-Stage HIV Disease Presentation at Initial HIV Diagnosis in Durban, South Africa  [PDF]
Paul K. Drain, Elena Losina, Gary Parker, Janet Giddy, Douglas Ross, Jeffrey N. Katz, Sharon M. Coleman, Laura M. Bogart, Kenneth A. Freedberg, Rochelle P. Walensky, Ingrid V. Bassett
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0055305
Abstract: Background After observing persistently low CD4 counts at initial HIV diagnosis in South Africa, we sought to determine risk factors for late-stage HIV disease presentation among adults. Methods We surveyed adults prior to HIV testing at four outpatient clinics in Durban from August 2010 to November 2011. All HIV-infected adults were offered CD4 testing, and late-stage HIV disease was defined as a CD4 count <100 cells/mm3. We used multivariate regression models to determine the effects of sex, emotional health, social support, distance from clinic, employment, perceived barriers to receiving healthcare, and foregoing healthcare to use money for food, clothing, or housing (“competing needs to healthcare”) on presentation with late-stage HIV disease. Results Among 3,669 adults screened, 830 were enrolled, newly-diagnosed with HIV and obtained a CD4 result. Among those, 279 (33.6%) presented with late-stage HIV disease. In multivariate analyses, participants who lived ≥5 kilometers from the test site [adjusted odds ratio (AOR) 2.8, 95% CI 1.7–4.7], reported competing needs to healthcare (AOR 1.7, 95% CI 1.2–2.4), were male (AOR 1.7, 95% CI 1.2–2.3), worked outside the home (AOR 1.5, 95% CI 1.1–2.1), perceived health service delivery barriers (AOR 1.5, 95% CI 1.1–2.1), and/or had poor emotional health (AOR 1.4, 95% CI 1.0–1.9) had higher odds of late-stage HIV disease presentation. Conclusions Independent risk factors for late-stage HIV disease presentation were from diverse domains, including geographic, economic, demographic, social, and psychosocial. These findings can inform various interventions, such as mobile testing or financial assistance, to reduce the risk of presentation with late-stage HIV disease.
Late Presentation to Care among People Living with HIV in Cotonou, Benin: A Retrospective Analysis from 2003 to 2014  [PDF]
Djimon Marcel Zannou, Pacos Bray Gandaho, Angèle Azon-Kouanou, Carin Ahouada, Kuessi Anthelme Agbodande, Armand Wanvoegbe, Jocelyn Akakpo, Fabien Houngbe
Open Journal of Internal Medicine (OJIM) , 2017, DOI: 10.4236/ojim.2017.74013
Abstract: Background: Late presentation to care is associated with increased morbidity, mortality and healthcare cost. Objectives: To determine the prevalence of late presentation to care in Benin, describe its trends and identify risk factors associated. Methods: We conducted a retrospective analysis from 2003 to 2014 at the National HIV Referral Centre in Benin. The definition of the European Late Presentation Consensus Group (ELPCG) for late presentation to care was used. Late Presenters (LP) were defined as patients presenting to care with CD4 count below 350 cells/mm3 or with an AIDS defining event, and patients with advanced HIV disease (AHD) were defined as persons with a CD4 count below 200 cells/mm3. Results: 5018 patients were included. Women accounted for 62.9%. Patients ranged in age from 18 to 62 years. 4233 patients (84.4%) were late presenters (LP) and 3126 (62.3%) were in Advanced HIV Disease (AHD). Late presentation decreased from 97.7% in 2003 to 78.7% in 2009. Between 2009 and 2014, there was no substantial decrease. Older age [Odds Ratio (OR) = 3.17; 95% Confidence Interval (CI) = [2.52 - 4.00], p < 0.001], male gender (OR = 1.85; 95% CI = [1.56 - 2.22], p < 0.001) and non-schooling (OR = 2.13; 95% CI [1.77 - 2.56], p < 0.001), were associated with late presentation to care. Being diagnosed through the Prevention of Mother To Child Transmission (PMTCT) of HIV, appeared as a protective factor (OR = 0.20; 95% CI [0.15 - 0.27], p < 0.001). Conclusions: The prevalence of late presentation to care in Cotonou is alarming. This prevalence has been on a declining trend, but it remains extremely high. In order to reach the first 90 of the 90-90-90 targets, policymakers should promote the Provider-initiated HIV Testing and Counselling in all health facilities, modeled on the existing PMTCT of HIV screening during pregnancy.
Late Relapse and Follow-up Protocols in Testicular Germ Cell Tumours: The Edinburgh Cancer Centre Experience and Review of the Literature
Beatrice Detti,Paul A. Elliott,Duncan B. McLaren,Grahame C.W. Howard
Clinical Medicine : Oncology , 2008,
Abstract: Aims: To identify clinicopathological features and outcomes in patients with late relapse (LR) of testicular germ cell tumours (GCTs) in order to guide follow-up policy.Materials and Methods: The Edinburgh Cancer Centre (ECC) database identified all patients diagnosed with testicular GCT between 1988 and 2002. Of 703 patients, six relapsed more than 24 months after their initial treatment. A retrospective case note review was performed to extract clinical, pathological, treatment and outcome data.Results: Six patients (0.85%) underwent late relapse. All patients presented initially with stage I disease and five were classified as good risk (International Germ Cell Consensus Classification, IGCCC). Median time to LR was 31 months. Two patients had previously relapsed less than 24 months from initial diagnosis. Markers at the time of relapse were normal in all patients. In all cases of late relapse disease was confined to axial lymphadenopathy. Three patients were treated with chemotherapy alone, two patients underwent surgical resection and one patient received combined treatment. All patients obtained a complete response and all remain disease free with a median follow-up of 52 months.Conclusions: The incidence of late relapse in this series is low. Chemo-naive patients with LR were successfully salvaged with chemotherapy alone and patients previously exposed to cisplatin-based chemotherapy were salvaged with complete surgical excision. The optimal length of follow-up in patients with testicular germ cell tumours is not known and practice varies widely. In this cohort of 703 patients, only one patient who relapsed was picked up by additional clinic follow-up between 5 and 10 years. Thus, on the basis of this small series, the authors suggest that follow-up after five years may not be justified.
Late termination of pregnancy by intracardiac potassium chloride injection: 5 years’ experience at a tertiary referral centre
L Govender, J Moodley
South African Medical Journal , 2013,
Abstract: Objectives. To report our experience with intracardiac potassium chloride (KCl) injection as a method of feticide for severe congenital abnormalities beyond 24 weeksf gestation. Method. A retrospective chart review. Patient demographics and types of fetal anomalies were analysed according to the groups that accepted or declined late termination of pregnancy (LTOP, .24 weeks) for severe congenital abnormalities. Results. Of 3 896 women referred to the Fetal Medicine Unit at Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, 2 209 (56.7%) were at .24 weeksf gestation at their first visit. LTOP for severe congenital abnormalities was offered to 253 (11.5%), of whom 191 (75.5%) accepted. Differences in maternal age, parity, race and religion were not statistically significant. The type of fetal abnormalities and gestational age at diagnosis influenced the decision-making process in >80% of the women. The most frequent indications for LTOP were brain and spinal abnormalities (53.0%), and aneuploidy (20.6%). Feticide by ultrasound-guided intracardiac KCl injection was performed in 138/191 cases (72.2%); 53 women who accepted LTOP did not undergo feticide for a variety of reasons. The mean interval between diagnosis and performance of feticide was 10 days (range 0 - 42 days). Fetal asystole was achieved in all cases within 2 minutes by a single-needle injection of intracardiac KCl; the mean duration of the procedure was 12 minutes (range 6 - 25 minutes). There were no maternal complications, and stillbirths occurred in all cases. Conclusion. Feticide by ultrasound-guided intracardiac KCl injection was an acceptable, safe and effective method for LTOP. Further studies are needed to determine the minimum dosage of KCl required to achieve the desired effect.
Hemolytic Uremic Syndrome: Late Renal Injury and Changing Incidence—A Single Centre Experience in Canada  [PDF]
Pierre Robitaille,Marie-José Clermont,A?cha Mérouani,Véronique Phan,Anne-Laure Lapeyraque
Scientifica , 2012, DOI: 10.6064/2012/341860
Abstract: Aims. To assess trends in the incidence of pediatric diarrhea-associated hemolytic uremic syndrome (D+ HUS) and document long-term renal sequelae. Methods. We conducted a retrospective cohort study of children with D+ HUS admitted to a tertiary care pediatric hospital in Montreal, Canada, from 1976 to 2010. In 2010, we recontacted patients admitted before 2000. Results. Of 337 cases, median age at presentation was 3.01 years (range 0.4–14). Yearly incidence peaked in 1988 and 1994-95, returning to near-1977 levels since 2003. Twelve patients (3.6%) died and 19 (5.6%) experienced long-term renal failure. Almost half (47%) The patients required dialysis. Need for dialysis was the best predictor of renal sequelae, accounting for 100% of severe complications. Of children followed ≥1 year ( , mean follow-up years), 19 had severe and 18 mild-to-moderate kidney injury, a total sequelae rate, of 18.6%. Ten years or more after-HUS ( , mean follow-up years), 8 (9.4%) patients demonstrated serious complications and 22 (25.9%) mild-to-moderate, including 14 (16%) microalbuminuria: total sequelae, 35.3%. Conclusions. Patients with D+ HUS should be monitored at least 5 years, including microalbuminuria testing, especially if dialysis was required. The cause of the declining incidence of D+HUS is elusive. However, conceivably, improved public health education may have played an important role in the prevention of food-borne disease. 1. Introduction Hemolytic uremic syndrome (HUS) is the most frequent cause of acute kidney injury in children. Approximately 5% of children with HUS die within the acute phase of the disease, with early studies reporting a mortality rate as high as 21% [1, 2]. As many as 25% of HUS survivors sustain long-term renal sequelae [3]. HUS is a systemic microangiopathy characterized by acute hemolytic anemia, thrombocytopenia, and renal failure [4]. In the classic or typical form, it is preceded by a prodrome of bloody diarrhea and gastroenteritis ( HUS) due to infection with strains of Escherichia coli (E. coli) that produce Shiga-like toxin, also known as verotoxin [3]. Shiga toxin-producing E. coli (STEC), or verotoxin-producing E. coli (VTEC), such as E. coli O157:H7 have been systematically recovered from stools of patients with HUS since the mid-1980s, when this association was clearly established [5]. An atypical form of HUS has also been described. Accounting for 5–10% of pediatric HUS cases, the atypical form HUS is due to a variety of causes, including complement pathway abnormalities [6]. The percentage of HUS patients presenting with
The Experience in Nicaragua: Childhood Leukemia in Low Income Countries—The Main Cause of Late Diagnosis May Be “Medical Delay”  [PDF]
C. De Angelis,C. Pacheco,G. Lucchini,M. Arguello,V. Conter,A. Flores,A. Biondi,G. Masera,F. Baez
International Journal of Pediatrics , 2012, DOI: 10.1155/2012/129707
Abstract: Background. The event-free survival for pediatric leukemia in low-income Countries is much lower than in high-income countries. Late diagnosis, which is regarded as a contributing factor, may be due to “parental” or “medical” delay. Procedures. The present study analyses determinants of lag time from first symptoms to diagnosis of leukemia, comparing pediatric (0–16 years old) patients in two referral centers, one in Nicaragua and one in Italy. An observational retrospective study was conducted to assess factors influencing the time to diagnosis. Results. 81 charts of children diagnosed with acute myeloid leukemia or lymphoblastic leukemia were analyzed from each centre. Median lag time to diagnosis was higher in Nicaragua than in Italy (29 versus 14 days, <0.001) and it was mainly due to “physician delay” (16.5 versus 7 days, <0.001), whereas “patient delay” from symptoms to first medical assessment was similar in the two centers (7 versus 5 days, =0.27). Moreover, median lag time from symptoms to diagnosis was decreased in Nicaraguan districts were a specific training program upon childhood oncological diseases was carried out (20.5 versus 40 days, =0.0019). Conclusions. Our study shows that delay in diagnosis of childhood leukemia is mainly associated with “physician delay” and it may be overcome by programs of continuous medical education.
The Experience in Nicaragua: Childhood Leukemia in Low Income Countries—The Main Cause of Late Diagnosis May Be “Medical Delay”  [PDF]
C. De Angelis,C. Pacheco,G. Lucchini,M. Arguello,V. Conter,A. Flores,A. Biondi,G. Masera,F. Baez
International Journal of Pediatrics , 2012, DOI: 10.1155/2012/129707
Abstract: Background. The event-free survival for pediatric leukemia in low-income Countries is much lower than in high-income countries. Late diagnosis, which is regarded as a contributing factor, may be due to “parental” or “medical” delay. Procedures. The present study analyses determinants of lag time from first symptoms to diagnosis of leukemia, comparing pediatric (0–16 years old) patients in two referral centers, one in Nicaragua and one in Italy. An observational retrospective study was conducted to assess factors influencing the time to diagnosis. Results. 81 charts of children diagnosed with acute myeloid leukemia or lymphoblastic leukemia were analyzed from each centre. Median lag time to diagnosis was higher in Nicaragua than in Italy (29 versus 14 days, ) and it was mainly due to “physician delay” (16.5 versus 7 days, ), whereas “patient delay” from symptoms to first medical assessment was similar in the two centers (7 versus 5 days, ). Moreover, median lag time from symptoms to diagnosis was decreased in Nicaraguan districts were a specific training program upon childhood oncological diseases was carried out (20.5 versus 40 days, ). Conclusions. Our study shows that delay in diagnosis of childhood leukemia is mainly associated with “physician delay” and it may be overcome by programs of continuous medical education. 1. Introduction Childhood leukemia is the most common childhood cancer, with an annual incidence of 4.5?:?100.000 [1]. The most common leukemia subtype is acute lymphoblastic leukemia (ALL) and the majority of affected patients (80%, 75.000 cases/year) live in low income countries (LIC). There, the estimated 5 years event-free survival (EFS) is only 35%, versus 75% in high income countries (HIC), due to difficulties in diagnosing and treating the disease or inadequate medical facilities and to socioeconomical factors [2–5]. Few studies have analyzed the determinants of lag time in the diagnosis of childhood cancer or leukemia [6–15]. Very few studies have been conducted to assess the impact of “medical delay” on timing of cancer diagnosis and only one research on leukemia in LIC is available to our knowledge [15]. The present study reports the lag time from first symptoms to diagnosis in childhood leukemia in the Referral Center of Nicaragua. The impact of physicians’ delay is analyzed and is compared with that of an HIC Center. 2. Materials and Methods The study (observational, retrospective) was run in the context of a twinning program for pediatric hematooncology started in 1986 between La Mascota Hospital in Managua (Nicaragua) and
Late HIV diagnosis is a major risk factor for intensive care unit admission in HIV-positive patients: a single centre observational cohort study  [cached]
Shrosbree Julia,Campbell Lucy J,Ibrahim Fowzia,Hopkins Phillip
BMC Infectious Diseases , 2013, DOI: 10.1186/1471-2334-13-23
Abstract: Background HIV positive patients are at risk of infectious and non-infectious complications that may necessitate intensive care unit (ICU) admission. While the characteristics of patients requiring ICU admission have been described previously, these studies did not include information on the denominator population from which these cases arose. Methods We conducted an observational cohort study of ICU admissions among 2751 HIV positive patients attending King’s College Hospital, South London, UK. Poisson regression models were used to identify factors associated with ICU admission. Results The overall incidence rate of ICU admission was 1.0 [95% CI 0.8, 1.2] per 100 person-years of follow up, and particularly high early (during the first 3 months) following HIV diagnosis (12.4 [8.7, 17.3] per 100 person-years compared to 0.37 [0.27, 0.50] per 100 person-years thereafter; incidence rate ratio 33.5 [23.4, 48.1], p < 0.001). In time-updated analyses, AIDS and current CD4 cell counts of less than 200 cells/mm3 were associated with an increased incidence of ICU admission while receipt of combination antiretroviral therapy (cART) was associated with a reduced incidence of ICU admission. Late HIV diagnosis (initial CD4 cell count <350 or AIDS within 3 months of HIV diagnosis) applied to 81% of patients who were first diagnosed HIV positive during the study period and who required ICU admission. Late HIV diagnosis was significantly associated with ICU admission in the first 3 months following HIV diagnosis (adjusted incidence rate ratio 8.72, 95% CI 2.76, 27.5). Conclusions Late HIV diagnosis was a major risk factor for early ICU admission in our cohort. Earlier HIV diagnosis allowing cART initiation at CD4 cell counts of 350 cells/mm3 is likely to have a significant impact on the need for ICU care.
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