Erica Miller

Survival, plasma HIV-1 RNA concentrations and drug resistance in HIV-1-infected Haitian adolescents and young adults on antiretrovirals

OBJECTIVE To assess outcomes after antiretroviral therapy (ART) in adolescents and youth in Haiti, a country with a generalized epidemic of infection with HIV-1. METHODS An assessment was made of survival, plasma HIV-1 ribonucleic acid (RNA) concentrations and HIV-1 drug resistance patterns after 12 months of ART in patients aged 13-25 years who presented to a clinic in Port-au-Prince, Haiti, with AIDS between 1 March 2003 and 31 December 2005. Participants received ART in accordance with WHO guidelines. Kaplan-Meier analysis was used to estimate survival probabilities and their 95% confidence intervals (CI) for the period from ART initiation to death. FINDINGS Of a total of 146 patients, 96 (66%) were female; the median CD4+ T-cell count at baseline was 129 cells/ml. By Kaplan-Meier analysis, 13% of the patients had died at 12 months, 17% at 24 months and 20% at 36 months. A plasma HIV-1 RNA concentration > or = 50 copies/ml was seen in 40 (51%) of 79 patients 12 months after treatment initiation and was associated with poor ART adherence. Among 29 patients with > 1000 copies/ml at 12 months, resistance mutations to non-nucleoside reverse transcriptase inhibitors (NNRTIs) were detected in 23 cases (79%); to both NNRTIs and lamivudine in 21 (72%) cases; and to NNRTIs, lamivudine and other nucleoside reverse transcriptase inhibitors in 10 (35%) cases. One hundred and six participants (73%) reported sexual intercourse without condoms, and 35 of the 96 women (36%) were pregnant during follow-up. CONCLUSION Adolescents and youth with AIDS receiving ART are at risk of virologic failure and disease progression and can therefore transmit HIV-1 to sexual partners and infants. Strategies to target the special needs of this age group are urgently needed.

AIDS diarrhea and antiretroviral drug concentrations: A matched-pair cohort study in Port au Prince, Haiti

Diarrhea in patients with acquired immunodeficiency syndrome (AIDS) may cause malabsorption of medications and failure of antiretroviral therapy (ART). We prospectively evaluated human immunodeficiency virus-1 (HIV-1)-infected patients with and without chronic diarrhea initiating ART in Haiti. We report mean plasma antiretroviral concentrations at 2 and 4 weeks. We measured plasma HIV-1 RNA levels at four points. Fifty-two HIV-1-infected patients (26 matched pairs) were enrolled. No differences in antiretroviral concentrations were detected. At week 24, 18/25 (72%) cases and 16/24 (68%) controls had undetectable plasma HIV-1 RNA levels (P = 0.69). Patients with plasma HIV-1 RNA levels > 50 copies/mL at week 24 had lower early efavirenz concentrations than patients with undetectable HIV-1 RNA (2,621 ng/mL versus 5,278 ng/mL; P = 0.02). Diarrhea at ART initiation does not influence plasma concentrations of the medications evaluated. Virologic outcome at Week 24 does correlate with efavirenz concentrations early in therapy but not with the presence of chronic diarrhea.

Cardiovascular risk assessment with regadenoson SPECT MPI in patients with end-stage renal disease is safe, effective, and well tolerated: Does it matter?

Patients with chronic kidney disease (CKD) constitute a special population that carries substantial risks of developing cardiovascular disease and complications of diagnostic and prognostic evaluation. Glomerular filtration rate (GFR) is inversely related to the rate of cardiovascular events, and patients with end-stage renal disease (ESRD) carry more than three times the risk of suffering a cardiovascular event compared with patients who have normal GFR. In recognition of this risk of excess morbidity and mortality of cardiovascular disease in this special population, the American College of Cardiology and the American Heart Association recommend considering CKD, a coronary heart disease risk equivalent. Diagnostic and prognostic assessments of patients with CKD pose serious potential safety concerns associated with the unique pathophysiology of CKD, including increased risk of iodinated contrast-induced nephropathy associated with invasive or CT coronary angiography, and nephrogenic systemic fibrosis with gadolinium cardiac magnetic resonance imaging. In patients with ESRD, mineralocorticoid excess, disordered bone and mineral metabolism, uremia, hyperhomocysteinemia, anemia, oxidative stress, inflammation, elevated norepinephrine and endothelin-1 levels cause vasoconstriction, frequent diabetes mellitus, depressed circulating endothelial progenitor cells (EPCs) for vascular repair, and enhanced vascular calcification which may predispose to the serious health risks of contrast exposure for diagnostic cardiac CT and MRI testing. The excess clinical cardiovascular morbidity and mortality, the diagnostic and prognostic evaluation risks, and the complex pathophysiologic metabolic, inflammatory, hormonal, and hematologic insults of patients with CKD including ESRD are compounded by underrepresentation in cohort studies validating methods for assessing cardiovascular disease in this special population. Pooled data from the ASSUAGE and ASSUAGECKD trials represent the largest prospective study of the use of regadenoson-stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in patients with CKD including ESRD and have established the safety and tolerability of regadenoson vasodilator stress SPECT imaging in this high-risk population. A remarkable finding of the ASSUAGE trial has been the high degree of patient satisfaction associated with routine reversal of regadenoson with aminophylline, with 91% patients receiving aminophylline reversal indicating they would definitely or probably be willing to repeat the test. Prior to the ASSUAGE-CKD Trial, safety concerns existed for the potential of serious adverse events associated with reduced excretion, enhanced exposure, and toxicity of regadenoson. These concerns seemed justified on the basis of the triphasic half life of regadenoson with a 2hour terminal elimination phase of regadenoson and Reprint requests: Ronald G. Schwartz, MD, MS, Cardiology Division, Department of Medicine, University of Rochester Medical Center, Box 679, Rochester, NY; ronald_schwartz@urmc.rochester.edu J Nucl Cardiol 2017;24:119–21. 1071-3581/

Quantitative Radionuclide Assessment of Cardiac Dyssynchrony: Breakthrough in Patient Selection for Cardiac Resynchronization Therapy for Refractory Heart Failure?

34.00 Copyright 2015 American Society of Nuclear Cardiology.

Common Adult Congenital Heart Disease Issues

An estimated 5.7 million adults with heart failure (HF) currently burden the human, medical, and financial resources of the United States. By 2030, this number is expected to increase to more than 8 million. In 2012, the total cost of HF in the United States was estimated at

Heart disease in pregnancy

30.7 billion, which is expected to increase to

A man with chest pain and acute ST elevations on electrocardiogram

69.7 billion by 2030. HF contributes substantially to mortality and is documented on 1 in 9 death certificates in the United States (1). HF mortality 1 y after diagnosis appears to be declining in the 21st century according to Medicare data: 31.7% in 1999 to 29.6% in 2008 (2). These improvements have been attributed to evidence-based approaches in the management of HF, including guideline-directed medical therapy, coronary revascularization, implantable cardioverter defibrillators, and cardiac resynchronization therapy (CRT) in which both the right and the left ventricles are paced synchronously to augment cardiac output (1).

Factors Associated with the Accurate Diagnosis of Obesity.

There are more adults than children living with congenital heart disease (CHD) in the United States. Most adults with congenital heart disease should be seen at least periodically by adult congenital heart disease (ACHD) specialists. The general cardiology consultant also has a unique opportunity to improve the care of patients with ACHD by improving access to care, while patients are interacting with the healthcare system for other reasons such as noncardiac surgery or pregnancy. This chapter describes the epidemiology of ACHD, issues with accessing healthcare, and transitioning patients from a pediatric to adult model of care. We will outline general approaches including society guidelines to common issues including hypertension, dyslipidemia, heart failure and transplantation, arrhythmias, liver disease, hyperviscosity, preoperative risk assessment, imaging, pregnancy, contraception, exercise, and infective endocarditis. Finally, we will briefly review some of the more commonly encountered forms of cyanotic and acyanotic ACHD and describe surgical treatments including shunts and the Fontan palliation procedure.

Survival, plasma HIV-1 RNA concentrations and drug resistance in HIV-1-infected Haitian adolescents and young adults on

Cardiovascular disease affects only 1–4 % of pregnancies, yet still accounts for nearly 12 % of pregnancy related deaths in the United States, making this the leading cause of non-obstetric mortality [1, 2]. It is also the most important cause of non-obstetric morbidity during pregnancy. Unfortunately, cardiovascular disease in pregnancy is often under recognized as a result of its rather low prevalence, even when pregnant women exhibit concerning signs or symptoms. Contributing to the diagnostic challenges, normal physiologic changes that occur during pregnancy can often mimic cardiac disease. The morbidity and mortality from cardiovascular disease in this population can be attributed to a combination of normal physiological changes, previously unrecognized heart disease, and higher risk pre-existing cardiac conditions. The epidemiology of pregnant women is also changing, with more pregnancies complicated by advanced maternal age, assistive reproductive technologies and congenital heart disease [2]. Cardiovascular disease does not necessarily preclude successful pregnancy, but can increase maternal and neonatal risk. Patients with pre-existing cardiac lesions and those at significant risk for acquired heart disease during pregnancy should be counseled in advance about their risk. To assist clinicians in counseling and management of cardiovascular disease in pregnancy, we have reviewed the pertinent literature. In this chapter, we will summarize changes in cardiovascular physiology that occur during pregnancy and then outline approaches to pre-existing and acquired heart disease in pregnancy.