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Crane HM, Nance RM, Ruderman SA, Haidar L, Tenforde MW, Heckbert SR, Budoff MJ, Hahn AW, Drumright LN, Ma J, Mixson LS, Lober WB, Barnes GS, McReynolds J, Attia EF, Peter I, Moges T, Bamford L, Cachay E, Mathews WC, Christopolous K, Hunt PW, Napravnik S, Keruly J, Moore RD, Burkholder G, Willig AL, Lindstrom S, Whitney BM, Saag MS, Kitahata MM, Crothers KA, Delaney JAC. Venous Thromboembolism Among People With HIV: Design, Implementation, and Findings of a Centralized Adjudication System in Clinical Care Sites Across the United States. J Acquir Immune Defic Syndr 2024; 95:207-214. [PMID: 37988634 PMCID: PMC11151789 DOI: 10.1097/qai.0000000000003339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/30/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND People with HIV (PWH) are at increased risk for venous thromboembolism (VTE). We conducted this study to characterize VTE including provoking factors among PWH in the current treatment era. METHODS We included PWH with VTE between 2010 and 2020 at 6 sites in the CFAR Network of Integrated Clinical Systems cohort. We ascertained for possible VTE using diagnosis, VTE-related imaging, and VTE-related procedure codes, followed by centralized adjudication of primary data by expert physician reviewers. We evaluated sensitivity and positive predictive value of VTE ascertainment approaches. VTEs were classified by type and anatomic location. Reviewers identified provoking factors such as hospitalizations, infections, and other potential predisposing factors such as smoking. RESULTS We identified 557 PWH with adjudicated VTE: 239 (43%) had pulmonary embolism with or without deep venous thrombosis, and 318 (57%) had deep venous thrombosis alone. Ascertainment with clinical diagnoses alone missed 6% of VTEs identified with multiple ascertainment approaches. DVTs not associated with intravenous lines were most often in the proximal lower extremities. Among PWH with VTE, common provoking factors included recent hospitalization (n = 134, 42%), infection (n = 133, 42%), and immobilization/bed rest (n = 78, 25%). Only 57 (10%) PWH had no provoking factor identified. Smoking (46%), HIV viremia (27%), and injection drug use (22%) were also common. CONCLUSIONS We conducted a robust adjudication process that demonstrated the benefits of multiple ascertainment approaches followed by adjudication. Provoked VTEs were more common than unprovoked events. Nontraditional and modifiable potential predisposing factors such as viremia and smoking were common.
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Affiliation(s)
- Heidi M Crane
- Department of Medicine, University of Washington, Seattle, WA
| | - Robin M Nance
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Lara Haidar
- Department of Pharmacy, University of Manitoba, Manitoba, CA
| | - Mark W Tenforde
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA, Torrance, CA
| | - Andrew W Hahn
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Jimmy Ma
- Department of Medicine, University of Washington, Seattle, WA
| | - L S Mixson
- Department of Medicine, University of Washington, Seattle, WA
| | - William B Lober
- Department of Medicine and Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Gregory S Barnes
- Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Justin McReynolds
- Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Engi F Attia
- Department of Medicine, University of Washington, Seattle, WA
| | - Inga Peter
- Department of Genetics, Mount Sinai University, New York NY
| | - Tesfaye Moges
- Department of Medicine, University of California, San Diego, CA
| | - Laura Bamford
- Department of Medicine, University of California, San Diego, CA
| | - Edward Cachay
- Department of Medicine, University of California, San Diego, CA
| | | | | | - Peter W Hunt
- Department of Medicine, University of California, San Francisco, CA
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Jeanne Keruly
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Greer Burkholder
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL
| | - Amanda L Willig
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL
| | - Sara Lindstrom
- Department of Genetics, University of Washington, Seattle, WA; and
| | | | - Michael S Saag
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Mari M Kitahata
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Joseph A C Delaney
- Department of Medicine, University of Washington, Seattle, WA
- Department of Medicine, University of Manitoba, Manitoba, CA
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2
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Derigubah CA, Nkansah C, Mensah K, Appiah SK, Osei‐Boakye F, Odame E, Owusu M, Serwaa D, Hubert MA, Bani SB, Kuugbee E, Issahaku RG, Debrah AY, Addai‐Mensah O. Plasma levels of fibrinolytic and coagulation biomarkers in HIV-infected individuals on highly active antiretroviral therapy: A case-control study in a Northern Ghanaian population. Health Sci Rep 2023; 6:e1436. [PMID: 37484058 PMCID: PMC10360046 DOI: 10.1002/hsr2.1436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/27/2023] [Accepted: 07/07/2023] [Indexed: 07/25/2023] Open
Abstract
Background and Aim Impaired coagulation and fibrinolysis have been implicated in thromboembolism in human immunodeficiency virus (HIV)-infected individuals. This study evaluated the plasma levels of plasminogen activator inhibitor-1 (PAI-1) and coagulation biomarkers in HIV-infected individuals on highly active antiretroviral therapy (HAART). Methods This matched case-control study from March to December, 2020 comprised 76 participants: 38 HIV-positive individuals on HAART and 38 apparently healthy HIV-negative individuals as controls. Blood samples were collected for prothrombin time (PT), activated partial thromboplastin time (aPTT), D-dimers, PAI-1, and soluble fibrin monomer complex (SFMC) estimations. The data were analysed using SPSS version 22.0 and statistical significance was set at p < 0.05. Results Activated partial thromboplastin time was significantly lower in HIV seropositive individuals on HAART compared with HIV seronegative controls (25.90 s vs. 29.0 s, p = 0.030); however, PT, SFMC, D-dimers, and PAI-1 were significantly higher among the HIV-seropositive individuals compared with the controls: PT: (16.29 s ± 2.16 vs. 15.15 s ± 2.60, p = 0.010), SFMC: [8.53 ng/mL (8.03-9.12) vs. 7.84 ng/mL (7.32-8.58), p = 0.005]), D-Dimer: [463.37 ng/mL (402.70-526.33) vs. 421.11 ng/mL (341.11-462.52), p = 0.015], and PAI-1: [12.77 ng/mL (10.63-14.65) vs. 11.27 ng/mL (10.08-12.95), p = 0.039]. PAI-1 showed a moderate positive correlation with D-Dimer (r = 0.659, p < 0.001) and SFMC (r = 0.463, p = 0.003) among HIV-positive individuals on HAART. There was a strong positive correlation between the plasma PAI-1 concentration and the HIV viral load (r = 0.955, p < 0.001). Conclusion HIV-seropositive individuals on HAART have deranged coagulation and fibrinolytic markers. Higher HIV viral load correlates strongly with elevated plasma levels of PAI-1 antigens. Periodic assessment of markers of coagulation and fibrinolysis be included in the management of HIV/AIDS in Ghana.
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Affiliation(s)
- Charles A. Derigubah
- Department of Medical Laboratory TechnologySchool of Applied Science and Arts, Bolgatanga Technical UniversityBolgatangaGhana
- Department of Medical DiagnosticsFaculty of Allied Health Sciences, Kwame Nkrumah University of Science and TechnologyKumasiGhana
| | - Charles Nkansah
- Department of HaematologySchool of Allied Health Sciences, University for Development StudiesTamaleGhana
- Department of Medical Laboratory SciencesFaculty of Health Science and Technology, Ebonyi State UniversityAbakalikiNigeria
| | - Kofi Mensah
- Department of HaematologySchool of Allied Health Sciences, University for Development StudiesTamaleGhana
- Department of Medical Laboratory SciencesFaculty of Health Science and Technology, Ebonyi State UniversityAbakalikiNigeria
| | - Samuel K. Appiah
- Department of HaematologySchool of Allied Health Sciences, University for Development StudiesTamaleGhana
- Department of Medical Laboratory SciencesFaculty of Health Science and Technology, Ebonyi State UniversityAbakalikiNigeria
| | - Felix Osei‐Boakye
- Department of Medical Laboratory TechnologyFaculty of Applied Science and Technology, Sunyani Technical UniversitySunyaniGhana
| | - Enoch Odame
- Department of Medical DiagnosticsFaculty of Allied Health Sciences, Kwame Nkrumah University of Science and TechnologyKumasiGhana
| | - Michael Owusu
- Department of Medical DiagnosticsFaculty of Allied Health Sciences, Kwame Nkrumah University of Science and TechnologyKumasiGhana
- Department of Molecular BiologyKumasi Centre for Collaborative Research (KCCR)KumasiGhana
| | - Dorcas Serwaa
- Department of Obstetrics and GynaecologyUniversity of MelbourneMelbourneAustralia
| | - Maxwell A. Hubert
- Department of Medical Laboratory ScienceKoforidua Technical UniversityKoforiduaGhana
| | - Simon Bannison Bani
- Department of Biomedical Laboratory SciencesSchool of Allied Health Sciences, University for Development StudiesTamaleGhana
| | - Eugene Kuugbee
- Department of Clinical Microbiology, School of Medicine and Health SciencesUniversity for Development StudiesTamaleGhana
| | | | - Alexander Y. Debrah
- Department of Medical DiagnosticsFaculty of Allied Health Sciences, Kwame Nkrumah University of Science and TechnologyKumasiGhana
| | - Otchere Addai‐Mensah
- Department of Medical DiagnosticsFaculty of Allied Health Sciences, Kwame Nkrumah University of Science and TechnologyKumasiGhana
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Spierling A, Smith DA, Kikano EG, Rao S, Vos D, Tirumani SH, Ramaiya NH. Chest CT Findings in Patients with HIV Presenting to the Emergency Department: A Single Institute Experience. Curr Probl Diagn Radiol 2023; 52:110-116. [PMID: 36333220 DOI: 10.1067/j.cpradiol.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 09/12/2022] [Accepted: 09/21/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE The aim of this study was to analyze chest CT imaging findings and relevant clinical factors in patients with HIV presenting to the emergency department (ED). MATERIALS AND METHODS A retrospective review was performed to identify patients with HIV who received chest CT imaging evaluation in the acute ED setting. Analyzed patients included adults with a known diagnosis of HIV who presented to the ED at a single tertiary care center between 2004 and 2020 and received chest CT imaging. Chest CT findings were assessed by 2 radiologist readers, and relevant clinical data were gathered. Statistical analysis was performed to determine if imaging and clinical factors demonstrate significant associations with CD4 count, viral load, and antiretroviral therapy status. RESULTS A total of 113 patients with HIV were identified who presented to the ED and underwent chest CT imaging evaluation (mean age 47 ± 11 years). Frequently detected chest CT findings included infectious pneumonia (24%), malignancy (11%), pleural effusion (17%), pericardial effusion (13%), and pulmonary embolism (4%). CD4 count, viral load, and active retroviral therapy demonstrated statistically significant associations with a number of key imaging and clinical factors, including presence of pneumonia, malignancy, average length of hospital admission, and survival. CONCLUSION Patients with HIV present with a wide range of imaging findings when presenting in the acute ED setting. CD4 count, viral load, and active retroviral therapy status demonstrate statistically significant associations with multiple key imaging findings and clinical factors. Chest CT plays an integral role in the clinical management of this unique patient population.
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Affiliation(s)
- Angela Spierling
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Daniel A Smith
- Department of Radiology, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH.
| | - Elias G Kikano
- Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Sanjay Rao
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Derek Vos
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sree H Tirumani
- Department of Radiology, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH
| | - Nikhil H Ramaiya
- Department of Radiology, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH
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4
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Luu B, Ruderman S, Nance R, Delaney JAC, Ma J, Hahn A, Heckbert SR, Budoff MJ, Crothers K, Mathews WC, Christopolous K, Hunt PW, Eron J, Moore R, Keruly J, Lober WB, Burkholder GA, Willig A, Chander G, McCaul ME, Cropsey K, O'Cleirigh C, Peter I, Feinstein M, Tsui JI, Lindstroem S, Saag M, Kitahata MM, Crane HM, Drumright LN, Whitney BM. Tobacco smoking and binge alcohol use are associated with incident venous thromboembolism in an HIV cohort. HIV Med 2022; 23:1051-1060. [PMID: 35343038 PMCID: PMC9515244 DOI: 10.1111/hiv.13309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/27/2022] [Accepted: 03/14/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND People with HIV (PWH) are at increased risk of cardiovascular comorbidities and substance use is a potential predisposing factor. We evaluated associations of tobacco smoking and alcohol use with venous thromboembolism (VTE) in PWH. METHODS We assessed incident, centrally adjudicated VTE among 12 957 PWH within the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort between January 2009 and December 2018. Using separate Cox proportional hazards models, we evaluated associations of time-updated alcohol and cigarette use with VTE, adjusting for demographic and clinical characteristics. Smoking was evaluated as pack-years and never, former, or current use with current cigarettes per day. Alcohol use was parameterized using categorical and continuous alcohol use score, frequency of use, and binge frequency. RESULTS During a median of 3.6 years of follow-up, 213 PWH developed a VTE. One-third of PWH reported binge drinking and 40% reported currently smoking. In adjusted analyses, risk of VTE was increased among both current (HR: 1.44, 95% CI: 1.02-2.03) and former (HR: 1.44, 95% CI: 0.99-2.07) smokers compared to PWH who never smoked. Additionally, total pack-years among ever-smokers (HR: 1.10 per 5 pack-years; 95% CI: 1.03-1.18) was associated with incident VTE in a dose-dependent manner. Frequency of binge drinking was associated with incident VTE (HR: 1.30 per 7 days/month, 95% CI: 1.11-1.52); however, alcohol use frequency was not. Severity of alcohol use was not significantly associated with VTE. CONCLUSIONS Current smoking and pack-year smoking history were dose-dependently associated with incident VTE among PWH in CNICS. Binge drinking was also associated with VTE. Interventions for smoking and binge drinking may decrease VTE risk among PWH.
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Affiliation(s)
- Brandon Luu
- Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | | | - Robin Nance
- University of Washington, Seattle, Washington, USA
| | - Joseph A C Delaney
- University of Washington, Seattle, Washington, USA
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jimmy Ma
- University of Washington, Seattle, Washington, USA
| | - Andrew Hahn
- University of Washington, Seattle, Washington, USA
| | | | | | | | | | | | - Peter W Hunt
- University of California, San Francisco, California, USA
| | - Joseph Eron
- University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | | | | | - Amanda Willig
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | - Karen Cropsey
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Inga Peter
- Mount Sinai Hospital, New York, New York, USA
| | | | | | | | - Michael Saag
- University of Alabama at Birmingham, Birmingham, Alabama, USA
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5
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Schapkaitz E, Jacobson BF, Libhaber E. Pregnancy Related Venous Thromboembolism-Associated with HIV Infection and Antiretroviral Therapy. Semin Thromb Hemost 2022; 49:355-363. [PMID: 36055274 DOI: 10.1055/s-0042-1754391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Human immunodeficiency virus (HIV) infection in pregnancy is associated with substantial morbidity and mortality. Improved access to effective antiretroviral therapy (ART) has shifted the spectrum of pregnancy-related complications among HIV-infected pregnant women. In addition to placental vascular complications and preterm delivery, increased rates of venous thromboembolism (VTE) have been described. HIV infection is characterized by immune activation, inflammation, and endothelial dysfunction, which contribute to the activation of coagulation and its prothrombotic consequences. Indeed, activated coagulation factors have been reported to be increased and natural anticoagulants reduced in HIV. Several mechanisms for this persistent prothrombotic balance on ART have been identified. These may include: co-infections, immune recovery, and loss of the gastrointestinal mucosal integrity with microbial translocation. In addition to the direct effects of HIV and ART, traditional venous and obstetric risk factors also contribute to the risk of VTE. A research priority has been to understand the mechanisms of VTE in HIV-infected pregnant women receiving suppressive ART and to translate this into HIV-specific thromboprophylaxis recommendations. Management requires a multidisciplinary approach and further studies are indicated to guide the prevention and management of pregnancy-associated VTE in this population. The current review describes the epidemiology, mechanisms, and management of VTE in HIV-infected women in pregnancy and the postpartum period.
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Affiliation(s)
- Elise Schapkaitz
- Department of Molecular Medicine and Hematology, University of Witwatersrand, Johannesburg, South Africa
| | - Barry F Jacobson
- Department of Molecular Medicine and Hematology, University of Witwatersrand, Johannesburg, South Africa
| | - Elena Libhaber
- Department of Research Methodology and Statistics, University of Witwatersrand, Johannesburg, South Africa
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6
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Elevated Risk of Venous Thromboembolism in People Living with HIV. Viruses 2022; 14:v14030590. [PMID: 35336997 PMCID: PMC8955815 DOI: 10.3390/v14030590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022] Open
Abstract
Human immunodeficiency virus (HIV) has been generally considered as a highly adaptive and rapidly evolving virus. It still constitutes a major public health problem all over the world despite an effective outcome in the prevention and reversal of the development and prognosis by using antiretroviral therapy. The salient question lies in the more frequent emergence of a series of comorbidities along with the prolongation of the life, which deeply affects the survival in such group. Venous thromboembolism (VTE) has been recognized to be the third most common cardiovascular condition within people living with HIV (PWH). In terms of its mechanism of action, the occurrence of VTE is quite multifactorial and complex in HIV. Prior exploration concerning the etiology of VTE in PWH identifies general, disease-specific, and miscellaneous factors for explaining its occurrence and development. VTE has constituted an important role in PWH and may increase its all-cause mortality. Therefore, it is quite necessary to understand VTE from the following aspects of epidemiology, pathophysiology, molecular mechanisms, and therapeutic interventions so as to balance the risks and benefits of anticoagulation and optimize corresponding treatment.
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7
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Chan KH, Ramahi A, Lim SL, Ahmed E, Suleiman A, Slim J, Shaaban HS. Left ventricular thrombus complicated by acute limb ischemia in a patient with HIV. Radiol Case Rep 2021; 16:2416-2420. [PMID: 34257771 PMCID: PMC8260751 DOI: 10.1016/j.radcr.2021.05.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 12/01/2022] Open
Abstract
Left ventricular thrombus typically occurs in patients with impaired left ventricular function such as aneurysm, dilated cardiomyopathy, or post-myocardial infarction. Untreated HIV infection is known to increase the risk of venous thromboembolism and cardiovascular disease. However, the pathophysiology remains uncertain; some studies have proposed chronic inflammation as the underlying etiology. Nonetheless, left ventricular thrombus is extremely rare among persons living with HIV with no known underlying cardiac disease. Herein, we report an unusual case of a 55-year-old homeless and heterosexual male with past medical history of HIV, who has mildly reduced left ventricular function and a nonmobile, medium size left ventricular thrombus. Patient was initially treated with therapeutic dose of enoxaparin, and subsequently developed acute embolic occlusion of right femoral artery that lead to an above knee amputation. To our knowledge, left ventricular thromboembolism complicated with acute embolic ischemia in persons living with HIV is extremely rare. The presenting case will definitely add to the current body of knowledge and will raise awareness among physicians, in recognizing the rare association between HIV and arterial thromboembolism.
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Affiliation(s)
- Kok Hoe Chan
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Amr Ramahi
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Su Lin Lim
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Eyad Ahmed
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Addi Suleiman
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA.,Department of Cardiology, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Jihad Slim
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA.,Department of Infectious Disease, Saint Michael's Medical Centre, New York Medical College, NJ, USA
| | - Hamid S Shaaban
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, NJ, USA.,Department of Hematology/Oncology, Saint Michael's Medical Centre, New York Medical College, NJ, USA
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8
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Gatechompol S, Avihingsanon A, Putcharoen O, Ruxrungtham K, Kuritzkes DR. COVID-19 and HIV infection co-pandemics and their impact: a review of the literature. AIDS Res Ther 2021; 18:28. [PMID: 33952300 PMCID: PMC8097669 DOI: 10.1186/s12981-021-00335-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/08/2021] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) was first detected in December 2019. In March 2020, the World Health Organization declared COVID-19 a pandemic. People with underlying medical conditions may be at greater risk of infection and experience complications from COVID-19. COVID-19 has the potential to affect People living with HIV (PLWH) in various ways, including be increased risk of COVID-19 acquisition and interruptions of HIV treatment and care. The purpose of this review article is to evaluate the impact of COVID-19 among PLWH. The contents focus on 4 topics: (1) the pathophysiology and host immune response of people infected with both SARS-CoV-2 and HIV, (2) present the clinical manifestations and treatment outcomes of persons with co-infection, (3) assess the impact of antiretroviral HIV drugs among PLWH infected with COVID-19 and (4) evaluate the impact of the COVID-19 pandemic on HIV services.
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9
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George JM, Kuriakose SS, Monroe A, Hou Q, Byrne M, Pau AK, Masur H, Hadigan C, Castel AD, Horberg MA. Utilization of Direct Oral Anticoagulants in People Living with Human Immunodeficiency Virus: Observational Data from the District of Columbia Cohort. Clin Infect Dis 2021; 71:e604-e613. [PMID: 32179901 DOI: 10.1093/cid/ciaa284] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/13/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have become first-line treatment for venous thrombotic events. DOAC prescribing trends among people living with human immunodeficiency virus (PWH) are not well described. The coadministration of DOACs with the antiretroviral (ARV) pharmacokinetic boosters ritonavir (RTV) or cobicistat (COBI) may be complicated by pharmacokinetic interactions. METHODS A longitudinal cohort study was conducted using the D.C. Cohort Database in Washington, D.C., from January 2011 to March 2017, to describe oral anticoagulant prescribing among PWH ≥ 18 years old and the prevalence of DOAC use with RTV or COBI. Data collection included demographic and clinical characteristics, ARV and anticoagulant prescriptions, and International Classification of Diseases Ninth and Tenth Edition diagnosis codes. RESULTS Among 8315 PWH, there were 236 anticoagulant prescriptions (96 DOAC, 140 warfarin) for 206 persons. PWH prescribed anticoagulants were predominantly Black (82%) and male (82%), with a mean age at anticoagulant initiation of 56 years. DOAC use increased from 3% of total anticoagulant prescribing in 2011 to 43% in 2016, accounting for 64% of all newly recorded anticoagulant prescriptions by 2016. There were 19 bleeding events recorded among 16 individuals. Despite the Food and Drug Administration label recommendation to avoid rivaroxaban with boosted ARVs, 41% remained on boosted ARVs after rivaroxaban initiation. CONCLUSIONS DOAC use increased substantially in PWH by 2016. Although rivaroxaban is not recommended with RTV or COBI, concomitant use was recorded in 41% of rivaroxaban recipients in this cohort. As DOAC usage increases, clinicians need to be aware of potential DOAC/ARV interactions in order to select the most appropriate oral anticoagulant and monitoring plan for PWH.
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Affiliation(s)
- Jomy M George
- Pharmacy Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Safia S Kuriakose
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Anne Monroe
- Milken Institute School of Public Health, George Washington University, Washington, D.C., USA
| | - Qingjiang Hou
- Population Health-Research, Cerner Corporation, Kansas City, Missouri, USA
| | - Morgan Byrne
- Milken Institute School of Public Health, George Washington University, Washington, D.C., USA
| | - Alice K Pau
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Henry Masur
- Clinical Center Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland, USA
| | - Colleen Hadigan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Amanda D Castel
- Milken Institute School of Public Health, George Washington University, Washington, D.C., USA
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
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10
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Agrati C, Mazzotta V, Pinnetti C, Biava G, Bibas M. Venous thromboembolism in people living with HIV infection (PWH). Transl Res 2021; 227:89-99. [PMID: 32693031 DOI: 10.1016/j.trsl.2020.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Abstract
The risk of venous thromboembolism (VTE) and of recurrent VTE remain elevated in people living with HIV compared to controls still with contemporary antiretroviral therapy (ART). The pathophysiology of VTE in HIV is multi factorial and includes an interplay among traditional risk factors, HIV-specific factors, behavioral factors, exposure to ART and other therapies, coinfections, and co-morbidities.
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Affiliation(s)
- Chiara Agrati
- Cellular Immunology and Pharmacology Laboratory, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy
| | - Valentina Mazzotta
- The Clinical and Research Department, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy
| | - Carmela Pinnetti
- The Clinical and Research Department, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy
| | - Gianluigi Biava
- The Clinical and Research Department, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy
| | - Michele Bibas
- The Clinical and Research Department, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy.
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11
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Jackson BS, Nunes Goncalves J, Pretorius E. Comparison of pathological clotting using haematological, functional and morphological investigations in HIV-positive and HIV-negative patients with deep vein thrombosis. Retrovirology 2020; 17:14. [PMID: 32571345 PMCID: PMC7310079 DOI: 10.1186/s12977-020-00523-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 06/16/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients infected with the human immunodeficiency virus (HIV) are more prone to systemic inflammation and pathological clotting, and many may develop deep vein thrombosis (DVT) as a result of this dysregulated inflammatory profile. Coagulation tests are not routinely performed unless there is a specific reason. METHODS We recruited ten healthy control subjects, 35 HIV negative patients with deep vein thrombosis (HIV negative-DVT), and 13 HIV patients with DVT (HIV positive-DVT) on the primary antiretroviral therapy (ARV) regimen-emtricitabine, tenofovir and efavirenz. Serum inflammatory markers, haematological results, viscoelastic properties using thromboelastography (TEG) and scanning electron microscopy (SEM) of whole blood (WB) were used to compare the groups. RESULTS The DVT patients (HIV positive and HIV negative) had raised inflammatory markers. The HIV positive-DVT group had anaemia in keeping with anaemia of chronic disorders. DVT patients had a hypercoagulable profile on the TEG but no significant difference between HIV negative-DVT and HIV positive-DVT groups. The TEG analysis compared well and supported our ultrastructural results. Scanning electron microscopy of DVT patient's red blood cells (RBCs) and platelets demonstrated inflammatory changes including abnormal cell shapes, irregular membranes and microparticle formation. All the ultrastructural changes were more prominent in the HIV positive-DVT patients. CONCLUSIONS Although there were trends that HIV-positive patients were more hypercoagulable on functional tests (viscoelastic profile) compared to HIV-negative patients, there were no significant differences between the 2 groups. The sample size was, however, small in number. Morphologically there were inflammatory changes in patients with DVT. These ultrastructural changes, specifically with regard to platelets, appear more pronounced in HIV-positive patients which may contribute to increased risk for hypercoagulability and deep vein thrombosis.
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Affiliation(s)
- Brandon S Jackson
- Department of Surgery, University of Pretoria, Pretoria, 0007, South Africa
| | | | - Etheresia Pretorius
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, Private Bag X1 Matieland, 7602, South Africa.
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12
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Bugatti A, Marsico S, Mazzuca P, Schulze K, Ebensen T, Giagulli C, Peña E, Badimón L, Slevin M, Caruso A, Guzman CA, Caccuri F. Role of Autophagy in Von Willebrand Factor Secretion by Endothelial Cells and in the In Vivo Thrombin-Antithrombin Complex Formation Promoted by the HIV-1 Matrix Protein p17. Int J Mol Sci 2020; 21:ijms21062022. [PMID: 32188077 PMCID: PMC7139864 DOI: 10.3390/ijms21062022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/29/2020] [Accepted: 03/11/2020] [Indexed: 12/13/2022] Open
Abstract
Although the advent of combined antiretroviral therapy has substantially improved the survival of HIV-1-infected individuals, non-AIDS-related diseases are becoming increasingly prevalent in HIV-1-infected patients. Persistent abnormalities in coagulation appear to contribute to excess risk for a broad spectrum of non-AIDS defining complications. Alterations in coagulation biology in the context of HIV infection seem to be largely a consequence of a chronically inflammatory microenvironment leading to endothelial cell (EC) dysfunction. A possible direct role of HIV-1 proteins in sustaining EC dysfunction has been postulated but not yet investigated. The HIV-1 matrix protein p17 (p17) is secreted from HIV-1-infected cells and is known to sustain inflammatory processes by activating ECs. The aim of this study was to investigate the possibility that p17-driven stimulation of human ECs is associated with increased production of critical coagulation factors. Here we show the involvement of autophagy in the p17-induced accumulation and secretion of von Willebrand factor (vWF) by ECs. In vivo experiments confirmed the capability of p17 to exert a potent pro-coagulant activity soon after its intravenous administration.
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Affiliation(s)
- Antonella Bugatti
- Department of Molecular and Translational Medicine, Section of Microbiology, University of Brescia Medical School, 25123 Brescia, Italy; (A.B.); (P.M.); (C.G.); (A.C.)
| | - Stefania Marsico
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036 Arcavacata di Rende, Italy;
| | - Pietro Mazzuca
- Department of Molecular and Translational Medicine, Section of Microbiology, University of Brescia Medical School, 25123 Brescia, Italy; (A.B.); (P.M.); (C.G.); (A.C.)
| | - Kai Schulze
- Helmholtz Center for Infection Research (HZI), Department of Vaccinology and Applied Microbiology, 38124 Braunschweig, Germany; (K.S.); (T.E.); (C.A.G.)
| | - Thomas Ebensen
- Helmholtz Center for Infection Research (HZI), Department of Vaccinology and Applied Microbiology, 38124 Braunschweig, Germany; (K.S.); (T.E.); (C.A.G.)
| | - Cinzia Giagulli
- Department of Molecular and Translational Medicine, Section of Microbiology, University of Brescia Medical School, 25123 Brescia, Italy; (A.B.); (P.M.); (C.G.); (A.C.)
| | - Esther Peña
- Cardiovascular Program ICCC, CiberCV, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain; (E.P.); (L.B.)
| | - Lina Badimón
- Cardiovascular Program ICCC, CiberCV, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain; (E.P.); (L.B.)
| | - Mark Slevin
- John Dalton Building, School of Healthcare Science, Manchester Metropolitan University, Manchester M1 5GD, UK;
| | - Arnaldo Caruso
- Department of Molecular and Translational Medicine, Section of Microbiology, University of Brescia Medical School, 25123 Brescia, Italy; (A.B.); (P.M.); (C.G.); (A.C.)
| | - Carlos A. Guzman
- Helmholtz Center for Infection Research (HZI), Department of Vaccinology and Applied Microbiology, 38124 Braunschweig, Germany; (K.S.); (T.E.); (C.A.G.)
| | - Francesca Caccuri
- Department of Molecular and Translational Medicine, Section of Microbiology, University of Brescia Medical School, 25123 Brescia, Italy; (A.B.); (P.M.); (C.G.); (A.C.)
- Correspondence:
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13
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A case of pulmonary infarction induced by undiagnosed HIV. Respir Med Case Rep 2020; 31:101293. [PMID: 33251107 PMCID: PMC7683264 DOI: 10.1016/j.rmcr.2020.101293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/04/2020] [Accepted: 11/04/2020] [Indexed: 11/23/2022] Open
Abstract
A 25-year-old Chinese man visited our institution due to fever and left chest pain. A chest CT showed infiltrative shadows with pleural effusion. Despite antibiotics treatment, his symptoms gradually worsened. The contrast CT showed deterioration of infiltrative shadows with thromboembolism in pulmonary arteries, suggesting pulmonary infarction. Thereafter, his HIV test turned out to be positive. His symptoms and radiological findings improved after initiation of an anticoagulant therapy. No known risk factors for thromboembolism were identified except HIV infection. The possibility of pulmonary thrombosis should be noted when the HIV patient with acute chest pain and pneumonia-like infiltrative shadow is seen.
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14
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Durand M, Sinyavskaya L, Jin YL, Tremblay CL, Ducruet T, Laskine M. Incidence of Venous Thromboembolism in Patients Living with HIV: A Cohort Study. AIDS Patient Care STDS 2019; 33:455-458. [PMID: 31682166 DOI: 10.1089/apc.2019.0154] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Madeleine Durand
- Service de Médecine interne du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Centre de recherche du CHUM, Montréal, Canada
| | | | - Yu Lan Jin
- Centre de recherche du CHUM, Montréal, Canada
| | - Cécile L. Tremblay
- Centre de recherche du CHUM, Montréal, Canada
- Service de microbiologie et infectiologie du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Thierry Ducruet
- Unité de recherche clinique appliquée du centre de recherche de l'hôpital Ste-Justine, Montréal, Canada
| | - Mikhael Laskine
- Service de Médecine interne du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Centre de recherche du CHUM, Montréal, Canada
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15
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Natarajan P, Joolhar F, Thangarasu S, Aboeed A, Win TT, Cobos E. Embolizing Massive Right Atrial Thrombus in a HIV-Infected Patient. J Investig Med High Impact Case Rep 2018; 6:2324709618802871. [PMID: 30283807 PMCID: PMC6166303 DOI: 10.1177/2324709618802871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/08/2018] [Accepted: 08/30/2018] [Indexed: 11/18/2022] Open
Abstract
The risk of thromboembolism is increased when associated with the human
immunodeficiency viral (HIV) infection. Various factors are involved in
promoting thrombosis, and the presence of a patent foramen ovale augments the
potential for a paradoxical embolism. We describe the case of a 56-year-old man
receiving antiretroviral therapy with features of right heart failure and
pulmonary embolism. Due to the high incidence of life-threatening
thromboembolism in the HIV-infected group, the need for long-term
anticoagulation has to be evaluated.
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Affiliation(s)
| | - Fowrooz Joolhar
- Kern Medical Center, Bakersfield, CA, USA.,2UCLA-David Geffen School of Medicine, Los Angeles, CA, USA
| | - Sudhagar Thangarasu
- Kern Medical Center, Bakersfield, CA, USA.,2UCLA-David Geffen School of Medicine, Los Angeles, CA, USA
| | - Ayham Aboeed
- Kern Medical Center, Bakersfield, CA, USA.,2UCLA-David Geffen School of Medicine, Los Angeles, CA, USA
| | - Theingi Tiffany Win
- Kern Medical Center, Bakersfield, CA, USA.,2UCLA-David Geffen School of Medicine, Los Angeles, CA, USA
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16
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Trends in pulmonary embolism in patients infected with HIV during the combination antiretroviral therapy era in Spain: A nationwide population-based study. Sci Rep 2018; 8:12137. [PMID: 30108235 PMCID: PMC6092411 DOI: 10.1038/s41598-018-29739-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 07/17/2018] [Indexed: 12/17/2022] Open
Abstract
Chronic infections are a major factor in the development of pulmonary embolism (PE). We aimed to evaluate the trends of PE-related hospitalizations and PE-related deaths in people living with HIV (PLWH) during the era of combination antiretroviral therapy (cART) through a retrospective study in Spain. Data were collected from the Minimum Basic Data Set (MBDS) between 1997 and 2013. The study period was fragmented into four calendar periods (1997–1999, 2000–2003, 2004–2007, and 2008–2013). The rate of PE-related hospitalizations remained stable in PLWH (P = 0.361). HIV-monoinfected patients had a higher incidence than HIV/HCV-coinfected patients during all follow-up [(98.7 (95%CI = 92.2; 105.1); P < 0.001], but PE incidence decreased in HIV-monoinfected patients (P < 0.001) and increased in HIV/HCV-coinfected patients (P < 0.001). Concretely, the rate of PE-related hospitalizations decreased significantly in patients monoinfected with HIV [from 203.6 (95%CI = 175.7; 231.6) events per 100,000 patient-years in 1997–1999 to 74.3 (95%CI = 66.1; 82.3) in 2008–2013; P < 0.001], while patients coinfected with HIV/HCV had a significant increase [from 16.3 (95%CI = 11; 21.6) in 1997–1999 to 53.3 (95%CI = 45.9; 60.6) in 2008–2013; P < 0.001]. The mortality rate of PE-related hospitalizations showed a similar trend as PE incidence. In conclusion, the epidemiological trends of PE in PLWH changed during the cART era, with decreases in incidence and mortality in HIV-monoinfected and increases in both variables in patients coinfected with HIV/HCV.
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Mampuya FK, Steinberg WJ, Raubenheimer JE. Risk factors and HIV infection among patients diagnosed with deep vein thrombosis at a regional/tertiary hospital in Kimberley, South Africa. S Afr Fam Pract (2004) 2018. [DOI: 10.1080/20786190.2018.1432135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- FK Mampuya
- Faculty of Health Sciences, Department of Family Medicine, University of the Free Sate , Bloemfontein, South Africa
| | - WJ Steinberg
- Faculty of Health Sciences, Department of Family Medicine, University of the Free Sate , Bloemfontein, South Africa
| | - JE Raubenheimer
- Faculty of Health Sciences, Department of Biostatistics, University of the Free Sate , Bloemfontein, South Africa
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18
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Alvaro-Meca A, Ryan P, Martínez-Larrull E, Micheloud D, Berenguer J, Resino S. Epidemiological trends of deep venous thrombosis in HIV-infected subjects (1997-2013): A nationwide population-based study in Spain. Eur J Intern Med 2018; 48:69-74. [PMID: 29102088 DOI: 10.1016/j.ejim.2017.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/09/2017] [Accepted: 10/16/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chronic infections may be a triggering factor as well as a risk factor of deep venous thrombosis (DVT). The purpose of this study was to analyze the epidemiological trends of hospital admissions related to DVT in human immunodeficiency virus (HIV)-infected patients during the combination antiretroviral therapy (cART) era, in relation to hepatitis C virus (HCV) serological status. METHODS We performed a retrospective study using the Spanish Minimum Basic Data Set. We selected HIV-infected subjects over 15years old with a hospital admission and DVT diagnosis (ICD-9-CM codes: 453.4x and 453.8x) between 1997 and 2013. Patients were classified according to HCV serology. We estimated the incidence (events per 100,000 patient-years) in four calendar periods (1997-1999, 2000-2003, 2004-2007, and 2008-2013). RESULTS Overall, the incidence of DVT-related hospitalizations had a significant upward trend in all HIV-infected patients (P<0.001), with significant differences between 1997-1999 and 2008-2013 [49.5 vs. 88.1 (P<0.001)]. Moreover, the incidence was higher in HIV-monoinfected patients than in HIV/HCV-coinfected patients during the entire follow-up (P<0.001). However, the incidence had a significant downward trend in HIV-monoinfected patients (P=0.002) and a significant upward trend in HIV/HCV-coinfected patients (P<0.001). Specifically, the incidence of DVT-related hospitalizations in HIV-monoinfected patients significantly decreased from 1997-1999 to 2008-2013 [142.7 vs. 103.1 (P=0.006)], whereas in HIV/HCV-coinfected patients, the incidence increased from 8.4 (1997-1999) to 70.7 (2008-2013) (P<0.001). CONCLUSIONS Our findings suggest that DVT is an emerging health problem among HIV-infected patients, with increasing incidence during the first 17years after the introduction of cART, particularly in HIV/HCV-coinfected patients.
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Affiliation(s)
- Alejandro Alvaro-Meca
- Unidad de Medicina Preventiva y Salud Pública, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Pablo Ryan
- Servicio de Medicina Interna, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - Dariela Micheloud
- Servicio de Urgencias, Hospital General Universitario "Gregorio Marañón", Madrid, Spain
| | - Juan Berenguer
- Unidad de Enfermedades Infecciosas/VIH, Hospital General Universitario "Gregorio Marañón", Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Salvador Resino
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain.
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19
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Differential Influence of the Antiretroviral Pharmacokinetic Enhancers Ritonavir and Cobicistat on Intestinal P-Glycoprotein Transport and the Pharmacokinetic/Pharmacodynamic Disposition of Dabigatran. Antimicrob Agents Chemother 2017; 61:AAC.01201-17. [PMID: 28848011 DOI: 10.1128/aac.01201-17] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 08/19/2017] [Indexed: 12/15/2022] Open
Abstract
Dabigatran etexilate (DE) is a P-glycoprotein (P-gp) probe substrate, and its active anticoagulant moiety, dabigatran, is a substrate of the multidrug and toxin extrusion protein-1 (MATE-1) transporter. The antiretroviral pharmacokinetic enhancers, ritonavir and cobicistat, inhibit both these transporters. Healthy volunteers received single doses of DE at 150 mg alone, followed by ritonavir at 100 mg or cobicistat at 150 mg daily for 2 weeks. DE was then given 2 h before ritonavir or cobicistat. One week later, DE was given simultaneously with ritonavir or cobicistat. No significant increases in dabigatran pharmacokinetic (PK) exposure or thrombin time (TT) measures were observed with the simultaneous administration of ritonavir. Separated administration of ritonavir resulted in a mean decrease in dabigatran PK exposure of 29% (90% confidence interval [CI], 18 to 40%) but did not significantly change TT measures. However, cobicistat increased dabigatran PK exposure (area under the concentration-versus-time curve from time zero to infinity and maximum plasma concentration) by 127% each (90% CI, 81 to 173% and 59 to 196%, respectively) and increased TT measures (33% for the area-under-the-effect curve from time zero to 24 h [90% CI, 22 to 44%] and 51% for TT at 24 h [90% CI, 22 to 78%]) when given simultaneously with dabigatran. Similar increases were observed when cobicistat was administered separately by 2 h from the administration of dabigatran. In all comparisons, no significant increase in the dabigatran elimination half-life was observed. Therefore, it is likely safe to coadminister ritonavir with DE, while there is a potential need for reduced dosing and prudent clinical monitoring with the coadministration of cobicistat due to the greater net inhibition of intestinal P-gp transport and increased bioavailability. (This study has been registered at ClinicalTrials.gov under identifier NCT01896622.).
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20
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Crothers K, Petrache I, Wongtrakool C, Lee PJ, Schnapp LM, Gharib SA. Widespread activation of immunity and pro-inflammatory programs in peripheral blood leukocytes of HIV-infected patients with impaired lung gas exchange. Physiol Rep 2016; 4:4/8/e12756. [PMID: 27117807 PMCID: PMC4848721 DOI: 10.14814/phy2.12756] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 03/13/2016] [Indexed: 01/17/2023] Open
Abstract
HIV infection is associated with impaired lung gas transfer as indicated by a low diffusing capacity (DLCO), but the mechanisms are not well understood. We hypothesized that HIV-associated gas exchange impairment is indicative of system-wide perturbations that could be reflected by alterations in peripheral blood leukocyte (PBL) gene expression. Forty HIV-infected (HIV(+)) and uninfected (HIV(-)) men with preserved versus low DLCO were enrolled. All subjects were current smokers and those with acute illness, lung diseases other than COPD or asthma were excluded. Total RNA was extracted from PBLs and hybridized to whole-genome microarrays. Gene set enrichment analysis (GSEA) was performed between HIV(+) versus HIV(-) subjects with preserved DLCO and those with low DLCO to identify differentially activated pathways. Using pathway-based analyses, we found that in subjects with preserved DLCO, HIV infection is associated with activation of processes involved in immunity, cell cycle, and apoptosis. Applying a similar analysis to subjects with low DLCO, we identified a much broader repertoire of pro-inflammatory and immune-related pathways in HIV(+) patients relative to HIV(-) subjects, with up-regulation of multiple interleukin pathways, interferon signaling, and toll-like receptor signaling. We confirmed elevated circulating levels of IL-6 in HIV(+) patients with low DLCO relative to the other groups. Our findings reveal that PBLs of subjects with HIV infection and low DLCO are distinguished by widespread enrichment of immuno-inflammatory programs. Activation of these pathways may alter the biology of circulating leukocytes and play a role in the pathogenesis of HIV-associated gas exchange impairment.
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Affiliation(s)
- Kristina Crothers
- Division of Pulmonary & Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Irina Petrache
- Division of Pulmonary & Critical Care Medicine, National Jewish Health, Denver, Colorado
| | - Cherry Wongtrakool
- Pulmonary Section, Department of Veterans Affairs Medical Center, Decatur, Georgia Division of Pulmonary, Allergy, Critical Care, & Sleep Medicine, Emory University, Atlanta, Georgia
| | - Patty J Lee
- Division of Pulmonary & Critical Care Medicine, Yale University, New Haven, Connecticut
| | - Lynn M Schnapp
- Division of Pulmonary & Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Sina A Gharib
- Division of Pulmonary & Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
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Ikama S, Nkoua M, Gombet T, Makani J, Mongo-Ngamami S, Ondze-Kafata L, Ellenga-Mbolla B, Kimbally-Kaky G. Évaluation du risque de maladie thromboembolique veineuse et de sa prévention chez des patients hospitalisés à Brazzaville. ACTA ACUST UNITED AC 2016; 41:182-7. [DOI: 10.1016/j.jmv.2016.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 01/24/2016] [Indexed: 10/22/2022]
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van den Dries LWJ, Gruters RA, Hövels-van der Borden SBC, Kruip MJHA, de Maat MPM, van Gorp ECM, van der Ende ME. von Willebrand Factor is elevated in HIV patients with a history of thrombosis. Front Microbiol 2015; 6:180. [PMID: 25814984 PMCID: PMC4356086 DOI: 10.3389/fmicb.2015.00180] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 02/19/2015] [Indexed: 11/21/2022] Open
Abstract
Background: Arterial and venous thrombotic events are more prevalent in HIV infected individuals compared to the general population, even in the era of combination antiretroviral therapy. Although the mechanism is not fully understood, recent evidence suggests a role for chronic immune activation. Methods: We reviewed the Dutch National HIV registry database for HIV infected patients in Rotterdam with a history of arterial or venous thrombosis and calculated the incidence. We collected samples from patients with and without thrombosis and compared plasma levels of lipopolysaccharide (LPS), LPS binding protein (LBP), soluble CD14 (sCD14), and von Willebrand Factor antigen level (vWF). Results: During a 10-year period, a total of 60 documented events in 14,026 person years of observation (PYO) occurred, resulting in an incidence rate of 2.50, 2.21, and 4.28 for arterial, venous and combined thrombotic events per 1000 PYO, respectively. The vWF was elevated in the majority of study subjects (mean 2.36 SD ± 0.88 IU/ml); we found a significant difference when comparing venous cases to controls (mean 2.68 SD ± 0.82 IU/ml vs. 2.20 SD ± 0.77 IU/ml; p = 0.024). This difference remained significant for recurrent events (mean 2.78 SD ± 0.75; p = 0.043). sCD14 was positively correlated with LPS (r = 0.255; p = 0.003). Conclusion: The incidence of venous thrombosis was two-fold higher in HIV infected patients compared to age-adjusted data from general population cohort studies. We couldn't find a clear association between immune activation markers to either arterial or venous thrombotic events. We observed a marked increase in vWF levels as well as a correlation of vWF to first and recurrent venous thrombo-embolic events. These findings suggest that HIV infection is an independent risk factor for coagulation abnormalities and could contribute to the observed high incidence in venous thrombosis. This could be a reason to prolong anti-thrombotic treatment in HIV patients with a history of thrombosis.
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Affiliation(s)
| | - Rob A Gruters
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Netherlands
| | | | - Marieke J H A Kruip
- Division of Hematology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Netherlands
| | - Moniek P M de Maat
- Division of Hematology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Netherlands
| | - Eric C M van Gorp
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Netherlands ; Division of Infectious Diseases, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Netherlands
| | - Marchina E van der Ende
- Division of Infectious Diseases, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Netherlands
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23
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Modi RA, McGwin G, Westfall AO, Powell DW, Burkholder GA, Raper JL, Willig JH. Venous thromboembolism among HIV-positive patients and anticoagulation clinic outcomes integrated within the HIV primary care setting. Int J STD AIDS 2014; 26:870-8. [PMID: 25414089 DOI: 10.1177/0956462414561033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/30/2014] [Indexed: 02/05/2023]
Abstract
The purpose of this study was to explore factors associated with venous thromboembolism (VTE) among a cohort of HIV-infected patients and to describe early outcomes of warfarin anticoagulation therapy treated in a pharmacist-based anticoagulation clinic (ACC). A nested case-control study was conducted using the University of Alabama at Birmingham 1917 HIV Clinic Cohort. Conditional logistic regression was used to estimate factors associated with VTE. Among HIV-infected VTE cases, ACC-managed patients were compared to primary care provider (PCP)-managed patients to determine Time within Therapeutic INR Range (TTR). CD4 < 200 cells/µl (OR = 4.50; 95% CI = 1.52, 13.37; p = 0.007) and prior surgical procedures (13.20; 1.56; 111.4; p = 0.018) demonstrated positive associations with VTE, whereas longer HIV duration demonstrated a negative association (0.87; 0.78, 0.98; p = 0.019). TTR was 56.2% among ACC-managed patients compared to 30.5% of PCP-managed patients (p = 0.174). Overall, prior surgical procedures and low CD4 count were associated with an increased risk of VTE among HIV-infected patients. Despite small sample size, patients managed in ACC tend to achieve greater proportion of TTR compared to those managed by PCPs, suggesting that this model of therapy may provide additional benefits to HIV-infected patients.
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Affiliation(s)
- Riddhi A Modi
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Gerald McGwin
- Department of Epidemiology, School of Public Health, UAB, Birmingham, AL, USA
| | | | - Deon W Powell
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Greer A Burkholder
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA University of Alabama School of Medicine (UAB), Birmingham, AL, USA
| | - James L Raper
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA University of Alabama School of Medicine (UAB), Birmingham, AL, USA
| | - James H Willig
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA University of Alabama School of Medicine (UAB), Birmingham, AL, USA
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Thachil J, Owusu-Ofori S, Bates I. Haematological Diseases in the Tropics. MANSON'S TROPICAL INFECTIOUS DISEASES 2014. [PMCID: PMC7167525 DOI: 10.1016/b978-0-7020-5101-2.00066-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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25
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Chandra A, Firth J, Sheikh A, Patel P. Emergencies related to HIV infection and treatment (part 2). Afr J Emerg Med 2013. [DOI: 10.1016/j.afjem.2013.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Kim AY, Wu RI. Case records of the Massachusetts General Hospital. Case 37-2013. A 41-year-old woman with malaise and chest and abdominal pain. N Engl J Med 2013; 369:2138-45. [PMID: 24283228 DOI: 10.1056/nejmcpc1209651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Patra S, Nagesh CM, Reddy B, Srinivas BC, Manjunath CN, Hegde M. Acute pulmonary embolism being the first presentation of undetected HIV infection: report of two cases. Int J STD AIDS 2013; 24:497-9. [PMID: 23970756 DOI: 10.1177/0956462412472836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Though HIV infection is considered as a hypercoagulable state, but occurrence of acute pulmonary embolism (PE) is rare and usually seen in the advanced stage of the disease. PE as a presentation in a case where there is no previous history of having HIV infection is very rare; a Medline search revealed only one case reported previously. We describe two cases who presented with acute PE and were treated; they were subsequently diagnosed as having HIV infection.
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Affiliation(s)
- S Patra
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bannerghatta Road, Bangalore , Karnataka 560069, India.
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Yusuf HR, Reyes N, Zhang QC, Okoroh EM, Siddiqi AEA, Tsai J. Hospitalizations of adults ≥60 years of age with venous thromboembolism. Clin Appl Thromb Hemost 2013; 20:136-42. [PMID: 23814170 DOI: 10.1177/1076029613493659] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We assessed the rates, trends, and factors associated with venous thromboembolism (VTE) diagnosis among hospitalizations of adults ≥60 years of age during the period 2001 to 2010. Data from the National Hospital Discharge Survey were used for this study. During the period 2001 to 2010, the estimated annual number of hospitalizations in which a VTE diagnosis was recorded, among adults ≥ 60 years of age, ranged from approximately 2 70 000 in 2001 to 4 23 000 in 2010. The rate of such hospitalizations per 1 00 000 US population ≥60 years of age ranged from 581 in 2001 to 739 in 2010. During the period 2001 to 2004, there was a significant increasing trend in the rate of hospitalizations with VTE among women ≥60 years of age. The factors positively associated with an increased risk of VTE diagnosis were female sex, summer and autumn seasons (compared with spring), venous catheterization, cancer, and greater length of hospital stay.
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Affiliation(s)
- Hussain R Yusuf
- 1Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Wang D, Melancon JK, Verbesey J, Hu H, Liu C, Aslam S, Young M, Wilcox CS. Microvascular Endothelial Dysfunction and Enhanced Thromboxane and Endothelial Contractility in Patients with HIV. ACTA ACUST UNITED AC 2013; 4:267. [PMID: 24967147 DOI: 10.4172/2155-6113.1000267] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
11 BACKGROUND The prevalence of cardiovascular disease is increased with human immunodeficiency virus (HIV) infection, but the mechanism is unclear. We hypothesized that HIV increases microvascular reactive oxygen species, thereby impairing endothelial function and enhancing contractility. 12 METHOD Subcutaneous microarterioles were isolated from gluteal skin biopsies in premenopausal, African American, HIV positive women receiving effective anti-retroviral therapy, but without cardiovascular risk factors except for increased body mass index (n=10) and healthy matched controls (n=10). The arterioles were mounted on myographs, preconstricted and relaxed with acetylcholine for: endothelium-dependent relaxation, endothelium-dependent relaxation factor (nitric oxide synthase-dependent relaxation), endothelium-dependent hyperpolarizing factor (potassium-channel dependent relaxation) and endothelium-independent relaxation (nitroprusside). Contractions were tested to endothelium-dependent contracting factor (acetylcholine contraction with blocked relaxation); phenylephrine, U-46,619 and endothelin-1. Plasma L-arginine and asymmetric dimethylarginine were measured by high performance capillary electrophoresis. 13 RESULTS The micro-arterioles from HIV positive women had significantly (% change in tension; P<0.05) reduced acetylcholine relaxation (-51 ± 6 vs. -78 ± 3%), endothelium-dependent relaxation factor (-28 ± 4 vs. -39 ± 3%), endothelium-dependent hyperpolarizing factor (-17 ± 4 vs. -37 ± 4%) and decreased nitric oxide activity (0.16 ± 0.03 vs. 0.70 ± 0.16 Δ unit) but unchanged nitroprusside relaxation. They had significantly enhanced endothelium-dependent contracting factor (+21 ± 6 vs. +7 ± 2%) and contractions to U-46,619 (+164 ± 10 vs. +117 ± 11%) and endothelin-1(+151 ± 12 vs. +97 ± 9%), but not to phenylephrine. There was enhanced reactive oxygen species with acetylcholine (0.11 ± 0.02 vs. 0.05 ± 0.01 Δ unit; P<0.05) and endothelin-1 (0.31 ± 0.06 vs. 0.10 ± 0.02 Δ unit; P<0.05). Plasma L-arginine: assymetric dimethyl arginine rates was reduced (173 ± 12 vs. 231 ± 6 μmol·μmol-1, P<0.05). 14 CONCLUSION Premenopausal HIV positive womenhad microvascular oxidative stress with severe endothelial dysfunction and reduced nitric oxide and arginine: assymetric dimethylarginine ratio but enhanced endothelial, thromboxane and endothelin contractions. These microvascular changes may herald later cardiovascular disease.
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Affiliation(s)
- Dan Wang
- Hypertension, Kidney and Vascular Research Center and the Division of Nephrology and Hypertension, Georgetown University, USA
| | | | | | - Haihong Hu
- Division of Infectious Disease and the Metropolitan Washington Women's HIV Study group, Georgetown University, Washington, USA
| | - Chenglong Liu
- Division of Infectious Disease and the Metropolitan Washington Women's HIV Study group, Georgetown University, Washington, USA
| | - Shakil Aslam
- Hypertension, Kidney and Vascular Research Center and the Division of Nephrology and Hypertension, Georgetown University, USA
| | - Mary Young
- Division of Infectious Disease and the Metropolitan Washington Women's HIV Study group, Georgetown University, Washington, USA
| | - Christopher S Wilcox
- Hypertension, Kidney and Vascular Research Center and the Division of Nephrology and Hypertension, Georgetown University, USA
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Tichelaar YIGV, Kluin-Nelemans HJC, Meijer K. Infections and inflammatory diseases as risk factors for venous thrombosis. A systematic review. Thromb Haemost 2012; 107:827-37. [PMID: 22437808 DOI: 10.1160/th11-09-0611] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 01/24/2012] [Indexed: 12/12/2022]
Abstract
Inflammation and venous thrombosis are intertwined. Only in the recent 15 years clinical epidemiological studies have focussed on inflammatory or infectious diseases as risk factors for venous thrombosis. Although a few reviews and many case reports or studies on these topic has been written, a review reporting relative or absolute risks for venous thrombosis has not been published yet. We performed a systematic review using Medline, Pubmed and Embase and found 31 eligible articles. Inflammatory bowel disease, ANCA-associated vasculitis, infections in general and more specifically, human immunodeficiency virus, pneumonia and urinary tract infections are associated with an increased risk of venous thrombosis.
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Affiliation(s)
- Y I G Vladimir Tichelaar
- Department of Hematology, Division of Hemostasis and Thrombosis, University Medical Center Groningen, Groningen, the Netherlands.
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Abstract
PURPOSE OF REVIEW Compared with vast literature on the clinical, imaging, and in-vivo microbiology aspects of HIV disease, there is less on biopsy pathology and even less on autopsy data. This review focuses on some current clinico-pathological issues, with indications of where there is less certainty than we would like. RECENT FINDINGS The most important change in causes of death in HIV disease, since the advent of highly active antiretroviral therapy (HAART), is the reduction of classical AIDS-defining opportunistic diseases, with the compensating increase in background comorbidities related to lifestyle, infections including the hepatitis viruses and HHV8, ageing, drug toxicity and immune reconstitution inflammatory syndrome phenomena. In low-income countries, HIV contributes significantly to maternal mortality. SUMMARY To understand HIV disease better and manage future patients better, we need more tissue clinico-pathological correlation, including quality biopsy and autopsy evaluations.
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Pathogenesis of HIV-associated pulmonary hypertension: potential role of HIV-1 Nef. Ann Am Thorac Soc 2011; 8:308-12. [PMID: 21653533 DOI: 10.1513/pats.201006-046wr] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Infection with HIV increases the risk for lung diseases, including noninfectious pulmonary hypertension (PH). HIV-associated PH (HIV-PH) is an important lung disease in HIV-infected persons who live longer with antiretrovirals. The early stages of HIV-PH may be overlooked by healthcare providers due to nonspecific symptoms, including progressive dyspnea and nonproductive cough. HIV-PH may be detected via chest radiographs, CT scans, or electrocardiograms, but Doppler echocardiography is the most useful screening test to identify candidates for right heart catheterization. HIV-PH has a poor prognosis with high mortality; improved biomarkers to identify earlier stages of PH would benefit clinical care. The HIV-PH mechanism remains unknown, but HIV proteins such as Tat and Nef may play a role. HIV-1 Nef is a broad-spectrum adaptor protein that may affect HIV-infected and uninfected pulmonary vascular cells. Studies in macaques suggest that Nef is important in HIV-PH pathogenesis because monkeys infected with a chimeric simian immunodeficiency virus (SIV) expressing HIV-nef (SHIVnef) alleles, but not monkeys infected with the native SIV, develop pulmonary vascular remodeling. Four consistent amino acid mutations arose spontaneously in Nef passaged in the monkeys. To translate these findings to humans, one research endeavor of the Lung HIV Study focuses on the identification of HIV nef mutations in HIV-infected individuals with PH compared with HIV-infected normotensive patients. We present some of the preliminary evidence. Ongoing longitudinal studies will establish the connection between Nef mutations and the propensity for HIV-PH.
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Refractory hypoxia in an HIV-infected patient--a diagnostic challenge. Am J Emerg Med 2011; 30:1322.e5-6. [PMID: 21871757 DOI: 10.1016/j.ajem.2011.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Accepted: 06/03/2011] [Indexed: 11/22/2022] Open
Abstract
A 39-year-old man with HIV presented to the emergency department for evaluation of dyspnea accompanied by fever, diffuse chest discomfort, dry cough, and fatigue for past 1 week. The patient described his dyspnea as exertional progressing over 1 week to rest dyspnea. He was prescribed antiretroviral therapy but was noncompliant. He had no paroxysmal nocturnal dyspnea, orthopnea, rash, oral thrush, or diarrhea. His last record CD4+ lymphocyte count and HIV viral load were 43 cells/mm3 and 178,0000 copies/mL, respectively. Vital signs included a temperature of 101°F, heart rate of 115 beats per minute, respiratory rate of 16 per minute, and pulse oxygenation of 91% on room air. Lung examination revealed decreased breath sounds bilaterally, and the remainder of the examination was unrevealing. Laboratory findings revealed leukocytosis and increased serum lactate dehydrogenase of 577 U/L (90-190 U/L), and chest radiograph showed a right lower lobe infiltrate and perihilar, bilateral interstitial infiltrates (Fig. 1A).
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HIV-Associated Venous Thromboembolism. Mediterr J Hematol Infect Dis 2011; 3:e2011030. [PMID: 21869916 PMCID: PMC3152452 DOI: 10.4084/mjhid.2011.030] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 06/24/2011] [Indexed: 01/31/2023] Open
Abstract
HIV infection has been recognized as a prothrombotic condition and this association has now been proven by a large number of studies with a reported VTE frequency among HIV-infected patients ranging from 0.19% to 7,63 %/year. HIV infection is associated with a two to tenfold increased risk of venous thrombosis in comparison with a general population of the same age. Some risk factors demonstrated a strongest association with VTE such as, low CD4+ cell count especially in the presence of clinical AIDS, protein S deficiency, and protein C deficiency. Whereas other risk factors are still controversial like protease inhibitor therapy, presence of active opportunistic infections and presence of antiphospholipid antibodies, including anticardiolipin antibodies and lupus anticoagulant. Physicians caring for HIV positive patients should be able to recognize and treat not only the well-known opportunistic infections and malignancies associated with this chronic disease, but also be alert to the less well-known complications such as thromboses. Pulmonary embolism should be included in the differential diagnosis when patients with HIV/AIDS have unexplained dyspnea or hypoxemia. In younger individuals with VTE, especially men, without other identifiable risk factors for VTE, HIV should be considered. Because interactions between warfarin and antiretrovirals is possible, health care providers should also be alert to the potential of dangerously high or low INRs when they are giving anticoagulants to patients with HIV infection who are undergoing antiretroviral therapy.
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Nutescu E, Chuatrisorn I, Hellenbart E. Drug and dietary interactions of warfarin and novel oral anticoagulants: an update. J Thromb Thrombolysis 2011; 31:326-43. [PMID: 21359645 DOI: 10.1007/s11239-011-0561-1] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Clinicians and patients around the world have been intrigued by the concept of developing an oral anticoagulant with a broad therapeutic window and few drug and dietary interactions that can be administered at fixed doses with no or minimal monitoring. The recently approved oral direct thrombin inhibitor dabigatran, along with the emerging oral anti-factor Xa inhibitors, rivaroxaban, apixaban, and edoxaban, have been developed to address many of the shortcomings of warfarin therapy. As warfarin is associated with extensive food and drug interactions, there is also a need to consider such interactions with the new oral anticoagulants. While to date few drug and dietary interactions have been reported with the new oral anticoagulants, it is still early in their development and clinical use cycle. Pharmacokinetic and pharmacodynamic profiles will have to be closely accounted for when determining the likelihood of a potential drug interaction prior to therapy initiation. As the list of drugs and supplements that interact with warfarin is continuously expanding, and the knowledge on drug interactions with the novel oral anticoagulants is still in its infancy, clinicians need to be vigilant when initiating any of these agents or when any changes in the patient's medication profile occur and perform a close screening for potential drug and dietary interactions. The objective of this paper is to give an update on drug and dietary interactions with warfarin and the novel oral anticoagulants, dabigatran, rivaroxaban, apixaban, and edoxaban.
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Affiliation(s)
- Edith Nutescu
- Department of Pharmacy Practice and Center for Pharmacoeconomic Research, University of Illinois at Chicago, College of Pharmacy, 833 S. Wood St. MC 886, Rm 164, Chicago, IL 60612, USA.
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