Care of the HIV-Positive Patient in the Emergency Department in the Era of Highly Active Antiretroviral Therapy

[Cardiovascular compromise in the infection by the human immunodeficiency virus]

Human immunodeficiency virus (HIV) infection was associated with increased morbidity and mortality, predominantly for opportunistic infections, before using antiretroviral therapy. With this, patients have experienced increased survival and cardiovascular compromise too. The etiology of these clinical conditions could be related to the infection itself, adverse events associated with antiretroviral therapy, or adverse events produced by the combination with other drugs. Some of these conditions have an acute onset, and their rapid recognition is vital for a better prognosis.

Abdominal Pain in the Immunocompromised Patient

Abdominal pain in an immunocompromised patient represents a common clinical scenario that may have uncommon causes. Evaluation relies first on identifying the immunocompromise, whether due to congenital immunodeficiencies, malignancy, hematopoietic stem cell transplant, solid organ transplant, or human immunodeficiency virus/acquired immunodeficiency syndrome. Based on this determination, the emergency physician may then build a focused differential of pathophysiologic possibilities. Careful evaluation is necessary given the absence of classic physical examination findings, and liberal use of laboratory and cross-sectional imaging is prudent. Conservative evaluation and disposition of these high-risk patients is important to consider.

A 1-Year Prospective French Nationwide Study of Emergency Hospital Admissions in Children and Adults with Primary Immunodeficiency

PURPOSE

Patients with primary immunodeficiency (PID) are at risk of serious complications. However, data on the incidence and causes of emergency hospital admissions are scarce. The primary objective of the present study was to describe emergency hospital admissions among patients with PID, with a view to identifying "at-risk" patient profiles.

METHODS

We performed a prospective observational 12-month multicenter study in France via the CEREDIH network of regional PID reference centers from November 2010 to October 2011. All patients with PIDs requiring emergency hospital admission were included.

RESULTS

A total of 200 admissions concerned 137 patients (73 adults and 64 children, 53% of whom had antibody deficiencies). Thirty admissions were reported for 16 hematopoietic stem cell transplantation recipients. When considering the 170 admissions of non-transplant patients, 149 (85%) were related to acute infections (respiratory tract infections and gastrointestinal tract infections in 72 (36%) and 34 (17%) of cases, respectively). Seventy-seven percent of the admissions occurred during winter or spring (December to May). The in-hospital mortality rate was 8.8% (12 patients); death was related to a severe infection in 11 cases (8%) and Epstein-Barr virus-induced lymphoma in 1 case. Patients with a central venous catheter (n = 19, 13.9%) were significantly more hospitalized for an infection (94.7%) than for a non-infectious reason (5.3%) (p = 0.04).

CONCLUSION

Our data showed that the annual incidence of emergency hospital admission among patients with PID is 3.4%. The leading cause of emergency hospital admission was an acute infection, and having a central venous catheter was associated with a significantly greater risk of admission for an infectious episode.

Mental disorders and HIV infection in the emergency department: epidemiology and gender differences

The management of patients with HIV infection who have comorbidity with psychiatric disorders, is a problem that is encountered relatively frequently in Emergency Departments. This retrospective study aims to evaluate the characteristics of HIV-infected patients who have been admitted for mental disorders and other conditions to an Emergency Department (ED) of Sardinia, Italy, in 2013. Regarding the associated psychiatric condition (25.5% of total sample) 46.3% had mood disorders, 38.9% psychotic disorders and 14.8% anxiety disorders, with no significant gender differences (p = 0.329). The analysis of the sample showed drug abuse in 29.2%. A concomitant infection with HBV or HCV was found in the history of almost half of the patients. Only in 24.5% of cases was there a drug treatment in administered urgently, and an admission to hospital was necessary in 34.3% of the total sample of patients. Among the admissions, 70.4% were admitted to a department of infectious diseases, but of these, only 54.4% had at the admission to the ED signs of acute infection. The management of those who had gained access to emergency services required not only the management of acute disease, but also consideration of which would be the most appropriate department to solve the main problem (infection, fever, agitation, decompensated cirrhosis). Poor patient compliance often makes it difficult to manage, as the analysis of the data shows, a relevant percentage of patients appeared to leave before completion.

Cardiovascular disease in human immunodeficiency virus-infection as a cause of hospitalization: a case-series in a General Hospital in Peru

Background

Cardiovascular disease in the context of human immunodeficiency virus infection has become a major clinical concern in recent years. In the current report we assess hospitalizations due to cardiovascular disease in human immunodeficiency virus patients in a Social Security reference hospital in Peru.

Methods

A retrospective study was carried out between January 1996 and December 2012 in a General Hospital in Lima, Peru.

Results

We included 26 patients hospitalized due to cardiovascular disease. Mean age was 46.3 years (SD 12.5), predominantly male (57.7%). Ten patients (38.4%) were in Acquired Immunodeficiency Syndrome stages. Seventeen (65.4%) received high-active-antiretroviral therapy. Eleven (42.3%) had cardiac involvement and 15 (57.7%) had non-cardiac vascular involvement. The most frequent causes of cardiac involvement were pericardial effusion and myocardial infarction. On the other hand, deep vein thrombosis and stroke were the most frequent for non-cardiac vascular involvement.

Conclusions

Cardiovascular disease is an important cause of hospitalization in Peruvian human immunodeficiency virus patients, with differences between immunosuppression stages. Further studies analyzing associated factors are warranted.

The impact of unstable housing on emergency department use in a cohort of HIV-positive people in a Canadian setting

The social-structural challenges experienced by people living with HIV (PHA) have been shown to contribute to increased use of the emergency department (ED). This study identified factors associated with frequent and nonurgent ED use within a cohort of people accessing antiretroviral therapy (ART) in a Canadian setting. Interviewer-administered surveys collected socio-demographic information; clinical variables were obtained through linkages with the provincial drug treatment registry; and ED admission data were abstracted from the Department of Emergency Medicine database. Multivariate logistic regression was used to compute odds of frequent and nonurgent ED use. Unstable housing was independently associated with ED use (adjusted odds ratio [AOR] =1.94, 95% confidence interval [CI] 1.24-3.04]), having three or more ED visits within 6 months of the interview date [AOR: 2.03 (95% CI: 1.07-3.83)] and being triaged as nonurgent (AOR = 2.71, 95% CI: 1.19-6.17). Frequent and nonurgent use of the ED in this setting is associated with conditions requiring interventions at the social-structural level. Supportive housing may contribute to decreased health-care costs and improved health outcomes amongst marginalized PHA.

Emergency department utilization among a cohort of HIV-positive injecting drug users in a Canadian setting

BACKGROUND

Human immunodeficiency virus (HIV)-positive injection drug users (IDUs) are known to be at risk for multiple medical problems that may necessitate emergency department (ED) use; however, the relative contribution of HIV disease vs. injection-related complications has not been well described.

OBJECTIVES

We examined factors associated with ED use among a prospective cohort of HIV-positive IDUs in a Canadian setting.

METHODS

We enrolled HIV-positive IDUs into a community-recruited prospective cohort study. We modeled factors associated with the time to first ED visit using Cox regression to determine factors independently associated with ED use. In sub-analyses, we examined ED diagnoses and subsequent hospital admission rates.

RESULTS

Between December 5, 2005 and April 30, 2008, 428 HIV-positive IDUs were enrolled, among whom the cumulative incidence of ED use was 63.7% (95% confidence interval [CI] 59.1-68.3%) at 12 months after enrollment. Factors independently associated with time to first ED visit included: unstable housing (hazard ratio [HR] 1.5; 95% CI 1.1-2.0) and reporting being unable to obtain needed health care services (HR 2.2; 95% CI 1.2-4.1), whereas CD4 count and viral load were non-significant. Skin and soft tissue infections accounted for the greatest proportion of ED visits (17%). Of the 2461 visits to the ED, 419 (17%) were admitted to the hospital.

CONCLUSIONS

High rates of ED use were observed among HIV-positive IDUs, a behavior that was predicted by unstable housing and limited access to primary care. Factors other than HIV infection seem to be driving ED use among this population in the post-highly active antiretroviral therapy era.

Metabolic and hepatobiliary side effects of antiretroviral therapy (ART)

Although antiretroviral therapy (ART) for human immunodeficiency virus (HIV) has been in use since 1987, the initiation of highly active ART has produced an increase in adverse drug reactions. This is a new challenge as many of the adverse drug reactions attributable to ART may be indistinguishable from non-drug-related illnesses. The emergency physician must be aware of the potential complications of ART as affected patients may present with nonspecific symptoms. The focus of this article is the metabolic and hepatobiliary adverse effects of ART.

Emergency department utilization by HIV-positive adults in the HAART era

Background

No published study has analyzed emergency department (ED) utilization by human immunodeficiency virus (HIV)-positive adults in the highly active antiretroviral therapy (HAART) era.

Aims

The purpose of this study is to describe the demographic and HIV-specific variables associated with ED utilization by HIV-positive adults and their diagnoses when discharged from the ED or subsequently from the hospital.

Methods

We conducted a retrospective cohort study of all HIV-positive adults cared for at a tertiary center HIV clinic and ED (1 January–31 December 2006). Demographic, HIV clinical, and HIV lab variables were abstracted from the clinic database. ED/hospital diagnoses coded by the ICD-9 Diseases/Injuries Tabular Index were abstracted from identified discharge records. We used multivariate logistic regression to compute odds ratios (OR) of ED utilization based on the abstracted variables. We described the cohort and diagnoses using descriptive statistics.

Results

A total of 356 patients met inclusion criteria. Their mean age was 42.7 years, and 77.2% of included patients were male; 52.5% were Caucasian and 47.5% non-Caucasian; 72 patients (20.2%) presented to the ED during the study period [153 visits; 37 (10.4%) required hospitalization (61/153 visits)]. Income level and mean 2006 viral load had a significant association (p < 0.05) with ED utilization. Of 155 ICD-9 ED discharge diagnoses, ill-defined symptoms/signs (25.2%), injury (18.7%), and musculoskeletal disorders (11.6%) were most prevalent. Of 450 ICD-9 hospital discharge diagnoses, endocrine/metabolic (13.3%), psychiatric (12.2%), infectious/parasitic (12%), and circulatory disorders (11.8%) were most prevalent.

Conclusion

In this study of HIV-positive adults, income level and mean 2006 viral load had a significant association with ED utilization. Noninfectious diagnoses were alone most prevalent in ED discharged, but not hospitalized, patients.

Recent Publications on Medications and Pharmacy

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