One goal of the HIV care continuum is achieving viral suppression (VS), yet disparities in suppression exist among subpopulations of HIV-infected persons. We sought to identify disparities in both the ability to achieve and sustain VS among an urban cohort of HIV-infected persons in care. Data from HIV-infected persons enrolled at the 13 DC Cohort study clinical sites between January 2011 and June 2014 were analyzed. Univariate and multivariate logistic regression were conducted to identify factors associated with achieving VS (viral load <200 copies/ml) at least once, and Kaplan–Meier (KM) curves and Cox proportional hazards models were used to identify factors associated with sustaining VS and time to virologic failure (VL≥200 copies/ml after achievement of VS). Among the 4,311 participants 95.4% were either virally suppressed at study enrollment or able to achieve VS during the follow-up period. In multivariate analyses, achieving VS was significantly associated with age (aOR: 1.04; 95%CI: 1.03–1.06 per 5-year increase) and having a higher CD4 (aOR: 1.05, 95% CI 1.04–1.06 per 100 cells/mm3). Patients infected through perinatal transmission were less likely to achieve VS compared to MSM patients (aOR: 0.63, 95% CI 0.51–0.79). Once achieved, most participants (74.4%) sustained VS during follow-up. Blacks and perinatally-infected persons were less likely to have sustained VS in KM survival analysis (log rank chi-square p≤0.001 for both) compared to other races and risk groups. Earlier time to failure was observed among females, Blacks, publically insured, perinatally infected, those with longer-standing HIV infection, and those with diagnoses of mental health issues or depression. Among this HIV-infected cohort, most people achieved and maintained VS; however, disparities exist with regard to patient age, race, HIV transmission risk, and co-morbid conditions. Identifying populations with disparate outcomes allows for appropriate targeting of resources to improve outcomes along the care continuum.
Splenic vein thrombosis (SVT) is a well-recognized complication of acute and chronic pancreatitis. It is associated with complications of significant gastrointestinal bleeding and high morbidity if the thrombus propagates. There is a need to consider several factors in choosing whether to anticoagulate the patient. We report a case of SVT in a patient with a previous history of pancreatitis who presented with abdominal pain, nausea, and vomiting to the hospital. At the hospital, a CT scan revealed SVT. This case highlights the importance of undergoing further studies regarding anticoagulation for treating SVT in patients at risk for gastrointestinal bleeding.
BackgroundHepatitis B (HBV) co-infection increases the risk for liver-related morbidity among HIV-infected patients. Department of Health and Human Services (DHHS) guidelines for the management of HIV/HBV co-infection recommend six-monthly monitoring of blood tests. We assessed longitudinal adherence to these guidelines among patients enrolled in the DC Cohort Study, a city-wide clinical cohort in Washington, DC.MethodsPatients ≥18 years old who were enrolled between January 1, 2011 and March 31, 2016 and had ≥6 months of follow-up were included. Advanced liver fibrosis was defined as having a FIB-4 score >3.25 calculated from same-day platelet, AST and ALT results. Viral suppression (VS) was defined as having undetectable HIV VL (<200 copies/mL). Chronic HBV status was determined using ICD 9 and 10 diagnosis codes. Clinical targets were defined as the proportion tested for HBV viral load (VL), platelet count and AST (markers of HBV care) along with HIV VL and CD4 count tests (markers of HIV care) every six months following enrollment.ResultsAmong 7,631 HIV-infected patients, 354 (4.6%) had chronic HBV among whom 22 (6.2%) had advanced fibrosis. Compared with HIV-mono-infected patients, HIV/HBV patients were more likely to be male (86% vs 72%, P < 0.001) and had a history of AIDS (49% vs 37%, P < 0.001). Although HIV VS was high in both groups, co-infected patients were less likely to have undetectable HIV VL (88% in HIV only vs 84% in HIV/HBV, P = 0.026). HIV/HBV patients were nearly four times less likely to be tested for HBV than for HIV VL in the first six months (21% vs 79%, P <0.0001) and eight times less likely in the last six months of observation (6% vs 49%, P <0.0001). Comparing the first six months to the last six months of observation, the proportion of patients tested for AST (77% and 50% P < 0.0001) and platelets (76% and 57% P < 0.0001) declined.ConclusionAdherence to the DHHS management guidelines for monitoring HBV VL among HIV/HBV co-infected patients was low. AST and platelet counts were monitored at a similar frequency to HIV VL, suggesting that these markers may have been checked as part of routine HIV care than for HBV monitoring. Focusing on adherence to guidelines may ensure early detection of complications and provide patients with timely and appropriate care.Disclosures All authors: No reported disclosures.
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare and life-threatening delayed drug hypersensitivity reaction characterized by skin eruption, fever and visceral involvement that typically presents in response to certain medications. Most publications focus on the clinical and dermatologic aspects of this syndrome. However, this report will describe clinicopathologic features of DRESS, focusing on the histologic and immunohistochemical findings in the skin, pericardium and cerebral cortex. This is the case of a 30-year-old African American HIV-positive woman, who was evaluated in the emergency department after experiencing chest pain for 1 week and generalized pruritus for 6 weeks. Highly active antiretroviral therapy (HAART) had been discontinued 1 week before presentation due to suspicion of an allergic reaction. After an extensive workup, her chest pain was diagnosed as pericarditis. Subsequently, she rapidly deteriorated, experiencing seizures and requiring intubation. She developed cerebral edema with transtentorial and uncal herniation on the 14th day of admission. Gross autopsy findings included uncal herniation, fibrinous pericarditis, and a diffuse erythematous rash over the dorsum of the hands and bilateral lower extremities. Microscopic findings included organizing fibrinous pericarditis, diffuse epidermal necrosis and mixed inflammatory infiltrate within vessel walls in the dermis. Sections from the cerebral cortex showed scattered areas with lymphocytic perivascular cuffing and invasion into the vessel walls by CD3-positive T lymphocytes (T cells). These T cells showed staining with TIA-1 and granzyme B, features consistent with a cytotoxic T cell infiltrate. The constellation of findings, including history of HAART, peripheral eosinophilia, pericarditis, and vasculitis in the skin and cerebral cortex, are consistent with DRESS. DRESS is an uncommon disorder; better characterization of the pathologic features will lead to better understanding of its pathogenesis, and potentially more targets for treatment.
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