HIV indicator condition-guided testing to reduce the number of undiagnosed patients and prevent late presentation in a high-prevalence area: a case-control study in primary care.

OBJECTIVES: Recent guidelines advocate accelerated provider-initiated HIV testing by general practitioners (GPs). We aimed to identify the number of patient consultations in six general practices in the South-East of Amsterdam, and the incidence of HIV indicator conditions reported in their medical files prior to diagnosis. METHODS: A cross-sectional search in an electronic general practice database. We used a case-control design to identify those conditions most associated with an HIV-positive status. RESULTS: We included 102 HIV cases diagnosed from 2002 to 2012, and matched them with 299 controls. In the year prior to HIV diagnosis, 61.8% of cases visited their GP at least once, compared with 38.8% of controls. In the 5 years prior to HIV diagnosis, 58.8% of HIV cases had exhibited an HIV indicator condition, compared with 7.4% of controls. The most common HIV-related conditions were syphilis and gonorrhoea. The most common HIV-related symptoms were weight loss, lymphadenopathy and peripheral neuropathy. During this period, average HIV prevalence among people aged 15-59 years increased from 0.4% to 0.9%. CONCLUSIONS: This study revealed many opportunities for HIV indicator condition-guided testing in primary care. As yet, however, HIV indicator conditions are not exploited as triggers for early HIV testing.

A colo-urachal-cutaneous fistula in an 88-year-old male.

INTRODUCTION: Urachus anomalies are remnants of the urachus, an embryonic connection between the fetal bladder and umbilicus. These anomalies usually remain asymptomatic but can cause symptoms in case of infection. An extremely rare complication of symptomatic urachal remnants is fistulizing to adjacant viscera. We describe the first case of diverticulitis associated sigmoid-urachal-cutaneous fistula. CASE REPORT: An 88-year-old male visited the outpatient clinic with intermittent bleeding and gassy discharge from his umbilicus. Examination showed a normal looking umbilicus with a small fissure at the bottom in which a 10 cm probe could be inserted. Laparotomy revealed a fistula extending from the umbilicus to a pus filled cyst superior to the bladder. A second fistula between the cyst and a mid-sigmoid diverticulum was identified. The involved sigmoid segment was resected. Pathological examination demonstrated no malignancy. DISCUSSION: Urachal remnants are extremely rare in adults. They typically present with abdominal pain or palpable masses. Additional imaging can aid the diagnostic process. CONCLUSION: Due to the risk of recurrence and malignant transformation complete surgical excision of urachal anomalies is the treatment of choice. This can be done in a 1-step or 2-step procedure.

Final adult height of children with inflammatory bowel disease is predicted by parental height and patient minimum height Z-score.

BACKGROUND: This study was designed to elucidate the contribution of parental height to the stature of children with inflammatory bowel disease (IBD), who often exhibit growth impairment. Accordingly, we compared patients' final adult heights and target heights based on measured parental heights and examined predictors of final adult height in pediatric IBD patients. METHODS: We prospectively analyzed the growth of 295 patients diagnosed between ages 1 and 18 (211 Crohn's disease [CD], 84 ulcerative colitis [UC]) and their family members (283 mothers, 231 fathers, 55 siblings). RESULTS: Twenty-two percent had growth impairment (height for age Z-score <-1.64, equivalent to <5th percentile on growth curve) in more than 1 measurement since diagnosis; most growth-impaired patients had CD (88% CD versus 12% UC). Parents of the growth-impaired group had lower mean height Z-scores compared to parents of nongrowth-impaired patients (-0.67 versus 0.02 for mothers [P < 0.001]; -0.31 versus 0.22 for fathers [P = 0.002]). For 108 patients who reached adult heights and had available parental heights, the growth-impaired group continued to demonstrate lower adult height Z-scores (-1.38 versus 0.07; P < 0.001). Adult heights were within 1 SD of target heights even for the growth-impaired group. Only 11.3% remained persistently growth-impaired in adulthood. Multivariate regression analysis demonstrated lower parental height and minimum patient height Z-score as significant predictors of lower final adult height in IBD. CONCLUSIONS: Parental height is a powerful determinant of linear growth even in the presence of chronic inflammation, and should be an integral part of the evaluation of growth in IBD children.