Prophylactic supplementation of phosphate, magnesium, and potassium for the prevention of refeeding syndrome in hospitalized individuals with anorexia nervosa.

Medical stabilization, nutrition rehabilitation, and weight restoration, while minimizing risk for the potentially fatal complication of refeeding syndrome, are the primary goals for the treatment of hospitalized individuals with anorexia nervosa and other restrictive-type eating disorders. The purpose of this review was to examine the literature exploring the prophylactic supplementation of phosphate, magnesium, and potassium, in addition to routine thiamin and multivitamin supplementation, for the prevention of refeeding syndrome in adolescents and adults with anorexia nervosa. Through evaluation of outcomes (including serum electrolyte levels and clinical signs and symptoms such as respiratory failure, cardiac failure, peripheral edema, rhabdomyolysis, and encephalopathy), three studies found that prophylactic supplementation of potassium, magnesium, and/or phosphate were effective in preventing refeeding syndrome or refeeding hypophosphatemia (a characteristic of refeeding syndrome). Although all studies found that prophylactic supplementation was effective in preventing refeeding syndrome, refeeding approaches (including the method, amount, and duration of nutrient delivery) as well as the populations studied varied considerably, making it difficult to arrive at specific recommendations for practice. Randomized controlled trials are needed to further examine the safety and effectiveness of prophylactic supplementation of phosphate, magnesium, and potassium on the prevention of refeeding syndrome, utilizing similar feeding and supplementation protocols.

Glandular fever and Epstein-Barr virus-related polyneuropathy: a life-threatening complication.

An 18-year-old woman presented with a 1-week history of sore throat, lethargy and fevers. She was subsequently diagnosed with glandular fever and was managed conservatively. Following 1 week of conservative measures, she developed acute upper airway obstruction requiring emergency surgical tracheostomy insertion. Further investigation including electromyography demonstrated multiple cranial nerve neuropathies.

Diagnosis and management of conductive hearing loss in children with trisomy 21.

AIM: The objective of this study is to review the prevalence and degree of hearing loss in children with trisomy 21, their response to intervention and the presence of concomitant pathologies. The project will also highlight the experiences of the children from their parents' and guardians' perspective and the link between perceived service quality and an objective improvement in their hearing after rehabilitation. METHODS: All patients with trisomy 21 who were referred to district general otolaryngology outpatient clinics between 2014 and 2016 were included. A retrospective analysis of the medical notes and audiograms along with a qualitative questionnaire to the children's parents was utilised to gather the information. RESULTS: The study showed that 77% (17/22) of children suffered from hearing loss, with a moderate degree being most prevalent. The majority of patients (14/17, 82%) were managed conservatively, undergoing a period of watchful waiting (9/17, 53%) or receiving hearing aids (5/17, 30%) and 3 of 17 (17%) were managed with grommet insertion. The improvement in hearing with hearing aids was comparable with grommet insertion and hearing aids scored highest in the post-intervention qualitative assessment with grommet insertion scoring the lowest. CONCLUSIONS: Functional hearing has been shown to be key in developing speech and language skills. In children with trisomy 21, behavioural and anatomical abnormalities make the diagnosis and intervention technically more challenging. This study demonstrates that in the absence of other otological symptoms, hearing loss can be managed effectively and with the least distress to the children with hearing aids.

Developing a Community of Practice for HIV Care: Supporting Knowledge Translation in a Regional Training Initiative.

INTRODUCTION: Ensuring knowledgeable, skilled HIV providers is challenged by rapid advances in the field, diversity of patients and providers, and the need to retain experienced providers while training new providers. These challenges highlight the need for education strategies, including training and clinical consultation to support translation of new knowledge to practice. New England AIDS Education and Training Center (NEAETC) provides a range of educational modalities including academic peer detailing and distance support to HIV providers in six states. We describe the interprofessional perspectives of HIV providers who participated in this regional program to understand success and areas for strengthening pedagogical modality, content, and impact on clinical practice. METHODS: This 2013 to 2014 mixed-methods study analyzed quantitative programmatic data to understand changes in training participants and modalities and used semistructured interviews with 30 HIV providers and coded for preidentified and emerging themes. RESULTS: Since 2010, NEAETC evolved modalities to a greater focus on active learning (case discussion, clinical consultation), decreasing didactic training by half (18-9%). This shift was designed to move from knowledge transfer to translation, and qualitative findings supported the value of active learning approaches. Providers valued interactive trainings and presentation of cases supporting knowledge translation. On-site training encouraged peer networking and sharing of lessons learned. Diversity in learning priorities across providers and sites validated NEAETC's approach of tailoring topics to local needs and encouraging regional networking. DISCUSSION: Tailored approaches resulted in improved provider-reported capacity, peer learning, and support. Future evaluations should explore the impact of this multipronged approach on supporting a community of practice and empowerment of provider teams.

Knowledge, Beliefs and Practices Regarding Antiretroviral Medications for HIV Prevention: Results from a Survey of Healthcare Providers in New England.

BACKGROUND: Antiretroviral treatment for HIV-infection before immunologic decline (early ART) and pre-exposure chemoprophylaxis (PrEP) can prevent HIV transmission, but routine adoption of these practices by clinicians has been limited. METHODS: Between September and December 2013, healthcare practitioners affiliated with a regional AIDS Education and Training Center in New England were invited to complete online surveys assessing knowledge, beliefs and practices regarding early ART and PrEP. Multivariable models were utilized to determine characteristics associated with prescribing intentions and practices. RESULTS: Surveys were completed by 184 practitioners. Respondent median age was 44 years, 58% were female, and 82% were white. Among ART-prescribing clinicians (61% of the entire sample), 64% were aware that HIV treatment guidelines from the Department of Health and Human Services recommended early ART, and 69% indicated they would prescribe ART to all HIV-infected patients irrespective of immunologic status. However, 77% of ART-prescribing clinicians would defer ART for patients not ready to initiate treatment. Three-fourths of all respondents were aware of guidance from the U.S. Centers for Disease Control and Prevention recommending PrEP provision, 19% had prescribed PrEP, and 58% of clinicians who had not prescribed PrEP anticipated future prescribing. Practitioners expressed theoretical concerns and perceived practical barriers to prescribing early ART and PrEP. Clinicians with higher percentages of HIV-infected patients (aOR 1.16 per 10% increase in proportion of patients with HIV-infection, 95% CI 1.01-1.34) and infectious diseases specialists (versus primary care physicians; aOR 3.32, 95% CI 0.98-11.2) were more likely to report intentions to prescribe early ART. Higher percentage of HIV-infected patients was also associated with having prescribed PrEP (aOR 1.19, 95% CI 1.06-1.34), whereas female gender (aOR 0.26, 95% CI 0.10-0.71) was associated with having not prescribed PrEP. CONCLUSIONS: These findings suggest many clinicians have shifted towards routinely recommending early ART, but not PrEP, so interventions to facilitate PrEP provision are needed.

Attitudes and Training Needs of New England HIV Care and Addiction Treatment Providers: Opportunities for Better Integration of HIV and Alcohol Treatment Services.

OBJECTIVES: Unhealthy alcohol use is common among HIV-infected patients and contributes to co-morbidities, cognitive decline, unprotected sex, and poor medication adherence. Studies consistently show missed opportunities to address unhealthy alcohol use as part of care. Although treatment of other drug use has been integrated into HIV care in some settings, more information is needed regarding provider attitudes regarding the need for integration of alcohol treatment and HIV care. METHODS: We surveyed 119 HIV and 159 addiction providers regarding the following domains: existing knowledge, desire for new knowledge (with subdomains relative advantage, compatibility, and complexity of integrating knowledge), and individual and program development needs. Scale scores for each domain were correlated with demographics to identify factors associated with training need. RESULTS: Both HIV and addiction providers reported agreement with statements of existing knowledge and the need for additional skills. The priority attributed to training, however, was low for both groups. Knowledge and perceived prevalence of HIV and unhealthy alcohol use increased with years of experience. Perceived prevalence correlated with compatibility but not the relative advantage of training. CONCLUSIONS: Though addressing alcohol use and HIV was acknowledged to be important, the priority of this was low, particularly early career providers. These providers may be important targets for training focusing on motivating coordination of care and skills related to assessment and counseling.

Recommendations and reality: perceived patient, provider, and policy barriers to implementing routine HIV screening and proposed solutions.

In 2006, the Centers for Diseases Control and Prevention (CDC) released recommendations calling for routine HIV testing to be offered to those ages 13 to 64 as a standard of general health care. This recommendation included a plan to conduct HIV testing as part of a general consent. The reasoning and evidence for this recommendation is supported by experts, patients, and sponsored screenings by the CDC. The rationale behind this approach includes that knowledge of one's HIV status helps (1) infected individuals adopt risk-reduction behaviors and access to life-prolonging treatment and (2) uninfected individuals maintain behaviors that reduce their risk of becoming infected. This article discusses the perceived patient, provider, and policy barriers to implementing routine HIV screening and proposed solutions that can be part of a nurse-led contribution to develop and adopt innovative, patient-centered care models that can address the need for screening.

Characteristics of anti-tuberculosis medication adherence in South Africa.

Adherence to anti-tuberculosis (TB) medications is a critical issue in limiting the spread of the disease throughout the world. In South Africa, medications to treat TB are available at no cost. The purpose of this study was to examine the characteristics of medication adherence in a sample of patients diagnosed with TB (N = 159). The relationships among sociodemographic variables, social support, quality of life, and adherence were explored in this cross-sectional and descriptive study. Self-report data were obtained from a community-based sample of TB-infected individuals who received care in outpatient clinics in Durban, South Africa. Data were collected from the 159 Zulu- and/or English-speaking respondents who agreed to participate in the study. Logistic regression analyses indicated that 41% of the variance in adherence was explained by the model, with nonadherent participants more likely to have less frequent symptoms and more available nutrition than their adherent counterparts. The adherent group was more likely to have increased symptoms, more days with nothing to eat, and fewer appointments with their health care provider. Implications for clinical practice and research are discussed.

Current clinical issues impacting the lives of patients living with HIV/AIDS.

By significantly delaying the onset of AIDS, highly active antiretroviral therapy (HAART) decreases the high rates of mortality and morbidity previously associated with HIV type 1 infection. However, to gain the therapeutic benefits of HAART, patients must commit to lifelong therapy, which carries an increased risk of multiple metabolic comorbidities, including dyslipidemia and hyperglycemia. Hyperlipidemia associated with HAART can be accompanied by abnormal accumulation of adipose tissue in the abdominal and dorsocervical regions, collectively known as lipodystrophy. Additionally, hyperglycemia associated with HAART causes development of type 2 diabetes mellitus. Moreover, patients experiencing adverse metabolic effects associated with HAART have an increased risk for developing cardiovascular disease. Currently, metabolic comorbidities in patients infected with HIV are managed by interventional pharmacotherapy. However, because HAART regimens already have such high pill burdens, treatment of comorbidities with additional drugs may lead to nonadherence. This article will review the differential metabolic effects of various HAART regimens and the clinical implications for patients living with HIV/AIDS.

Challenges and opportunities for patients with HIV who educate health professionals.

BACKGROUND: Patient perspectives are valuable for clinical care and teaching. PURPOSE: To understand personal and programmatic effects of using HIV-infected persons as teachers in courses about care of HIV-infected people. METHODS: Semistructured interviews with HIV-infected faculty for New England AIDS Education and Training Center (NEAETC), addressing teaching decision and its personal, medical, and psychological consequences. Interview transcripts were analyzed via iterative, consensus building. RESULTS: Participants reported consequences of teaching that benefited them as patients (finding health care providers, increasing their knowledge base, and receiving tangible rewards such as gifts). A deeper level of benefit was realized personally, increasing control over their life and disease. Relationships, personal and professional, changed, from unilateral to mutual, heightening a sense of their own empowerment. Teaching built support networks and aided in coping with difficult issues raised (negative emotions, informing significant others about their infection, death and dying). Program support was essential for participation, allowing numerous teachers to transform teaching from individual messages to universal lessons. CONCLUSIONS: The program was well received and well regarded by participating teachers. Convenience sampling does not account for nonparticipating faculty viewpoints or those who left the program, but concrete benefits can be expected if support and investment by the program is in place. Learning by these HIV-infected teachers fits the characteristics of transformational learning.

Out of sight, out of mind: the impact of 9/11 on HIV-positive persons.

Providing care and support for persons living with HIV (PLWHIV) is an enormous challenge for providers throughout the world. At the same time, the cost of care both financially and emotionally continues to be quite expensive. Signs of caregiver burnout and public apathy were already taking a toll on providers, PLWHIV, and their families when the 9/11 tragedy occurred. The impact of the tragedy has significantly affected PLWHIV, providers, and families day-to-day lives in many ways. This study reveals the initial impact during the first few months after the 9/11 event.

Physical and sexual abuse in the lives of HIV-positive women enrolled in a primary medicine health maintenance organization.

Over the past several years, the proportion of all cases of AIDS in the United States among adult and adolescent women has more than tripled from 7% in 1985 to 23% in 1998. Information obtained in the present study suggests that care providers need to be aware of the unique life circumstances of women with AIDS, which may predispose them to a number of negative health and mental health outcomes. Charts of the first 100 women enrolled in an intensive home-based primary medical HMO for people with advanced HIV/AIDS were examined retrospectively for evidence of trauma. Results from a chart review and nursing care assessments of these patients revealed that women with HIV/AIDS were significantly more likely to have had traumatic life experiences compared to the larger population [as measured in a National Comorbidity Survey (NCS)]. In this study, one-half of the patients reported a lifetime history of sexual assault compared to 9% of the general population, one-third reported a history of incest compared to 12% in the NCS, and 83% reported significant physical abuse compared to 4% in the NCS. Such traumatic life experiences are frequently associated with high rates of psychiatric comorbidity, substance abuse, and possible nonadherence to health care. Providers of AIDS care need to be aware of the complex mental health and psychosocial needs of traumatized women with AIDS and make better use of collateral mental health providers and consultation. The ways in which this particular sample of women may be nonrepresentative of women living with AIDS, in general, including the observation that they may be a particularly traumatized and challenging cohort, and other limitations of the data, including the methods used for chart review, are discussed.