Objective We report rates and risk factors for attrition in the first cohort of patients followed through all stages from HIV testing to ART initiation. Design Cohort study of all patients diagnosed with HIV between January and June, 2009. Methods We calculated the proportion of patients who completed CD4 cell counts and initiated ART or remained in pre-ART care during two years of follow-up, and assessed predictors of attrition. Results Of 1,427 patients newly diagnosed with HIV, 680 (48%) either initiated ART or were retained in pre-ART care for the subsequent two years. One thousand eighty-three patients (76%) received a CD4 cell count and 973 (90%) returned for result; 297 (31%) had CD4 cell count < 200 cells/μl and of these, 256 (86%) initiated ART. Among 429 patients with CD4 > 350 cells/μl, 215 (50%) started ART or were retained in pre-ART care. Active TB was associated with lower odds of attrition prior to CD4 cell count (OR: 0.08; 95% CI: 0.03–0.25) but also higher odds of attrition prior to ART initiation (OR: 2.46; 95% CI: 1.29–4.71). Lower annual income (≤ $US125) was associated with higher odds of attrition prior to CD4 cell count (OR 1.65; 95% CI: 1.25–2.19), and prior to ART initiation among those with CD4 cell count > 350 cells/μl (OR: 1.74; 95% CI: 1.20–2.52). After tracking patients through a national database, the retention rate increased to only 57%. Conclusion Fewer than half of patients newly diagnosed with HIV initiate ART or remain in pre-ART care for two years in a clinic providing comprehensive services. Additional efforts to improve retention in pre-ART are critically needed.
Vascular thrombosis is a common clinical feature of both essential thrombocythemia (ET) and heparin-induced thrombocytopenia (HIT). The development of HIT in a patient with ET is rare and underrecognized. We report the case of a 77-year-old woman with preexisting ET, who was admitted with acute coronary syndrome, and IV heparin was started. She was exposed to unfractionated heparin (UFH) 5 days prior to this admission. Decrease in platelet count was noted, and HIT panel was sent. Heparin was discontinued. Patient developed atrial fibrillation, and Dabigatran was started. On day three, patient also developed multiple tiny cerebral infarctions and acute right popliteal DVT. On day ten of admission, HIT panel was positive, and Dabigatran was changed to Lepirudin. Two days later, Lepirudin was also discontinued because patient developed pseudoaneurysm on the right common femoral artery at the site of cardiac catheterization access. A progressive increase in the platelet count was noted after discontinuing heparin. Physicians should be aware of the coexistence of HIT and ET, accompanied challenges of the prompt diagnosis, and initiation of appropriate treatment.
Vaccination is the principal tool aimed at curbing the COVID-19 pandemic that has, so far, affected tens of millions of individuals in the United States. The two available mRNA vaccines developed by Pfizer-BioNTech and Moderna possess high efficacy in preventing infection and illness severity. However, there are multiple side effects associated with these vaccines, some impacting different organs. Renal pathology is variable, with increasing cases of glomerulonephritis being observed. We report a rare acute kidney injury case due to antineutrophil cytoplasmic autoantibody (ANCA)-mediated glomerulonephritis after administering a second dose of the Pfizer-BioNTech mRNA SARS-CoV-2 vaccine. Aggravation and/or development of autoimmunity after mRNA vaccination may involve multiple immune mechanisms leading to de novo and recurrent glomerular diseases with an autoimmune basis.
Ischemic monomelic neuropathy (IMN) is a relatively uncommon and under-recognized complication of vascular access creation for arteriovenous (AV) fistula in hemodialysis patients. They usually develop distal muscle weakness, sensation loss, and severe acute pain without muscle necrosis soon after AV fistula creation. Physicians should be aware of this condition as prompt diagnosis and timely vascular interventions are necessary to save the limbs and prevent permanent functional disability. Once the diagnosis of IMN is made, the patients will need emergent ligation of the fistula to restore the distal perfusion. We report a case of a 59-year-old male patient with End-stage Renal Disease on hemodialysis who developed severe pain, weakness, and loss of sensation in the left arm a few hours after left brachiocephalic vascular access creation. He was subsequently diagnosed with ischemic monomelic neuropathy and underwent emergent AV fistula ligation. Symptoms were relieved immediately after the ligation.
The principal objective of this systematic review is to determine the prognosis of end-stage renal disease (ESRD) patients on maintenance hemodialysis with high body mass index (BMI) and study the potential mechanisms behind it. PubMed and Google Scholar electronic databases covering the period of the last 30 years 1992 to 2022 are searched thoroughly and a total of 11 articles were finally selected for the study. Reference lists of included papers are also searched. Each paper was examined by two independent evaluators who also extracted data from full papers. The quality of the selected studies was assessed by different quality assessment tools and only moderate- to high-quality papers are included. In this systematic review, we studied different mechanisms explaining the obesity paradox in patients on maintenance hemodialysis, i.e., hemodynamic stability, the concentration of TNF-α receptors, neurohumoral response, role of inflammation, blood pressure, etc. also, the effect of age, gender, duration of treatment, acetyl-ghrelin on obesity paradox have been considered in our paper. This systematic review demonstrates the evidence of an inverse relationship between BMI and all-cause mortality in ESRD patients on maintenance hemodialysis.
Purpura fulminans is a devastating thrombotic disorder infrequently encountered in medical practice and amongst the medical literature. It is a hematologic emergency in which prompt recognition and initiation of treatment are critical to mitigate its significant morbidity and mortality. Surgical evaluation is commonly required, since the debilitating skin and soft tissue necrosis often degenerate into necrotizing fasciitis, critical limb ischemia, warranting surgical interventions in either a staged or single-step approach. Purpura fulminans can be neonatal, infectious, or idiopathic. Infection-induced purpura fulminans is less common, and only a few microorganisms have been associated with this condition: Meningococcus spp., Pneumococcus spp., or Staphylococcus spp. This report presents a rare case of Escherichia coli-induced purpura fulminans. Apart from the unfortunate partial amputation of all left-hand five digits, our patient made a full recovery following effective infectious source control, supportive care with volume resuscitation, anticoagulation, and wound care.
The primary goal of this research is to identify the factors of intradialytic hypertension in hemodialysis patients and stabilize blood pressure (BP) even without antihypertensive medicines. There are various treatment alternatives for lowering BP in these patients, many of which do not require extra pharmacological therapy (e.g. long, slow hemodialysis; short, daily hemodialysis; nocturnal hemodialysis; or, most effectively, dietary salt and fluid restriction in addition to the reduction of dialysate sodium concentration). These parameters provide good monitoring of BP, even with previously diagnosed hypertension. The adjustment of the extracellular volume with a low incidence of intradialytic hypotensive episodes is the most plausible explanation for this outcome.We did a systematic evaluation of all published articles since 1994 to evaluate antihypertensive drug outcomes in hemodialysis patients. All articles were searched in the English language using PubMed and Google Scholar databases. The screening techniques, study selection, data extraction procedures, and risk evaluation of bias were done using specified criteria and overseen by one of the senior writers with the application of quality assessment tools to the final articles. Data were searched using regular and MeSH (Medical Subject Headings) keywords. Although substantial developments have emerged in the medical field, there is still a significant knowledge gap in the sector, particularly when it comes to BP guidelines and therapy choices for hypertensive hemodialysis patients. Until additional data are available, we should treat hypertension in hemodialysis with the use of active pursuit of euvolemia using dry weight probing and reduction of salt excess.
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