CHALLENGES IN MANAGEMENT OF WARFARIN ANTI-COAGULATION IN ADVANCED HIV/AIDS PATIENTS WITH VENOUS THROMBOTIC EVENTS--A CASE SERIES FROM A RESEARCH CLINIC IN RURAL KERICHO, KENYA.

BACKGROUND: Venous thrombotic events (VTE) occur at high ratesin HIV/AIDS patients and are likely under-diagnosed in rural sub-Saharan Africa. OBJECTIVE: To describe clinical presentations and challenges in the management of VTE in patients with advanced HIV/AIDS. DESIGN: Case series from patients enrolled in a prospective observational cohort study. SETTINGS: A clinical research centre in rural Kericho, Kenya. SUBJECTS: Two hundred patients with median age 38 (30-47) years, BMI 16.9 (12.4-20.3) kg/m2, haemoglobin 9.3 (6.8-13.4) g/dL, CD4+ T-cell count 27 (4-77) cells/mm and plasma HIV RNA 5.23 (3.70-5.88) log10 copies/mL. INTERVENTIONS: VTE cases were diagnosed by clinical presentation and Doppler/ radiographic confirmation. Anti-coagulation therapy was managed by a multidisciplinary team; patients were initiated on enoxaparin or heparin followed by warfarin. RESULTS: Over two years,11patients (5.5%) experienced VTE. All but one (10/11,90.9%) case occurred within six months of starting ART. Nine patients had peripheral VTE (five popliteal, four femoral) and two had cerebral sinus thromboses. VTE was diagnosed 52 (1-469) days after ART initiation, and 81.8% of cases were outpatients at presentation. All patients received at least one concomitant medication that could significantly interact with warfarin (efavirenz, nevirapine, lopinavir/ritonavir, rifampicin, trimethoprim-sulfamethoxazole, and fluconazole). A median of 39 (10-180) days and eight (4-22) additional clinic visits were required to achieve/maintain a therapeutic INR of 2-3. Two minor bleeding complications occurred. No recurrent VTE cases were observed. CONCLUSION: Consideration of VTE and preparedness for management in patients with advanced HIV/AIDS starting ART is critical in sub-Saharan Africa. Overcoming challenges in anti-coagulation is possible in rural settings using a multidisciplinary team approach.

Recognition and management of significant drug interactions in HIV patients: challenges in using available data to guide therapy.

Combination antiretroviral therapy (cART) has improved survival rates in HIV-infected patients; however, patients now experience comorbidities that require pharmacological intervention, thereby increasing the risk of drug-drug interactions (DDIs). HIV protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and the CCR5 antagonist maraviroc are primarily metabolized via the cytochrome P450 (CYP) system and are prone to pharmacokinetic interactions.(1,2) This article addresses some key challenges that prescribers face when using available drug interaction-data resources in making day-to-day clinical decisions.

Emotional intelligence and stress coping in dental undergraduates--a qualitative study.

OBJECTIVE: To explore how dental undergraduates with different levels of emotional intelligence (EI) cope with stress. DESIGN: Qualitative unstructured depth interviews. SETTING: A dental teaching hospital in the UK, 2002. SUBJECTS AND METHODS: Subjects selected from the undergraduate population of a 5-year dental degree course. A questionnaire survey was carried out to determine the EI scores of the subjects. In each year of study, subjects were divided into low and high EI groups at the median score. From each EI group in each year, one male and one female subject were recruited. DATA COLLECTION: Unstructured face-to-face interviews. DATA ANALYSIS: Transcribing, sifting, indexing and charting data according to key themes. RESULTS: 10 males and 10 females with low and high EI, representing all 5 years of study were interviewed. The experience of stress, expressed in emotional terms, ranged from anger and frustration to hatred. Four sets of coping strategies, adopted at varying degrees according to EI, were identified. High EI students were more likely to adopt reflection and appraisal, social and interpersonal, and organisation and time-management skills. Low EI students were more likely to engage in health-damaging behaviours. CONCLUSIONS: Future research needs to establish whether the enhancement of EI in dental students would lead to improved stress-coping, and better physical and psychological health.

The use of PBL to facilitate the development of professional attributes in second year dental students.

OBJECTIVES: To investigate dental students' perception as to whether PBL can facilitate the development of professional attributes. DESIGN: A cross-sectional survey of second year dental undergraduates in a UK dental school. METHOD: At the end of a PBL module, all students were asked to complete a fully structured questionnaire. Data were collected on socio-demographics, aspects of the PBL experience and the extent to which students perceived that PBL had facilitated the development of professional attributes. RESULTS: The response rate was 96%. The frequency distributions of the PBL experience and development of professional attributes were skewed to the positive. Non-white students, compared to white students, rated significantly more highly the extent to which they thought PBL had facilitated the development of professional attributes. Differences between male and female students, and mature and less mature students were not significant. Students who rated the PBL experience positively were significantly more likely to rate highly the extent to which they thought PBL had facilitated the development of professional attributes. CONCLUSIONS: The factors that affect the relationship between ethnicity and development of professional attributes need further research. To enhance the development of professional attributes, teachers of PBL need to ensure that students find the learning experience worthwhile and stimulating.

Tobacco cessation, oral pain, and psychological distress in Bangladeshi women.

This study reports the experience of oral pain and psychological distress following tobacco cessation in Bangladeshi women. A cross-sectional survey was carried out in which telephone interviews were conducted in the Sylheti language by two female Bangladeshi researchers using structured questionnaires. Study participants were 58 Bangladeshi women, aged 22-60 years, who had recently given up chewing paan-with-tobacco. The General Health Questionnaire (GHQ-12) was used to measure psychological distress. A questionnaire on pain description, location, duration, onset, and intensity also was administered. Logistic regression analysis was carried out to explore the relationships between psychological distress and age, chewing characteristics, and the oral pain experience. The response rate was 100%. Of the sample, 22% reported having pain for 2 days and 28% for at least 1 week, 65% reported that the pain started by itself, 69% reported the intensity as mild or discomforting, and 52% experienced psychological distress. Significant predictors for high psychological distress were number of daily paan (odds ratio, OR=1.13), current tooth problem (OR=4.60), pounding pain (OR=6.50), pain onset (OR=3.21), and pain intensity (OR=5.57). The prevalence of oral pain reported for Bangladeshi women following an attempt at chewing tobacco cessation is high. Characteristics of this outcome suggest the pain is of dental origin. These characteristics are correlated to psychological distress. The success of chewing tobacco cessation initiatives in the population may be influenced by oral pain and psychological distress. Further research is needed to explore the etiological factors associated with oral pain in this group of tobacco users.

Prevalence estimates and associated factors for dental pain: a review.

PURPOSE: To assess the methodological quality of epidemiological studies on dental pain and review the published literature for its prevalence, and association with age, gender and socio-economic status. MATERIALS AND METHODS: Medline and reference lists of relevant articles were searched for observational studies published in English from 1966 to 2001 carried out on humans aged 19 years and over. Articles for reading of the full text were selected by two reviewers independently. Selected articles were assessed independently by the two reviewers according to a set of 8 standardized criteria. Inter-rater agreement was measured using the kappa statistic. Disagreements were discussed and a final score for each study agreed. Data on prevalence estimates and their distribution by age, gender and socio-economic factors were extracted. RESULTS: 422 studies were identified, and 23 selected for review. Inter-rater agreement was high for all 8 criteria used (kappa > 0.6). Methodological quality was poor with the number of criteria fulfilled by each study ranging from 1 to 6, median score 3. The prevalence estimates for 5 case definitions identified were: 'toothache' 7-32%, 'pain in teeth with hot, cold or sweet things' 25-38%, 'pain and discomfort needing medication or treatment' 7-9%, 'pain or discomfort in the mouth, teeth or gums' 19-66%, and 'oral and facial pain'40-44%. Younger subjects and those from lower socio-economic groups were more likely to report pain. Gender was not associated with dental pain. CONCLUSION: Epidemiological data on dental pain are sparse and of poor quality. There is a need for well-designed surveys using randomly selected community samples and standardized measurement criteria to fill this knowledge gap.

A dental practice placement scheme: benefits for practitioners and undergraduates.

OBJECTIVES: To report the feedback from general dental practitioners (GDPs) and dental undergraduates who participated in a general dental practice placement scheme. METHODS: Subjects All 61 students in a year made 2 to 3 full day visits, individually or in pairs, to 44 general dental practices allocated to them. Thirty four GDPs completed and returned the questionnaire, representing a response rate of 77%. Data collection Formal feedback from the students and GDPs were obtained through 6 structured seminar sessions and a postal questionnaire respectively. Analysis Sifting, indexing and charting the data according to key issues and themes. RESULTS: All 61 students attended the feedback sessions, 34 GDPs (response rate 77%) returned the questionnaire. The two most common themes that students reported having gained insight into were personal/professional development and practice management. The common positive aspects reported by the GDPs included exposure to the General Dental Service (GDS), motivation for undergraduate training and benefits for GDPs. These benefits included encouragement for the GDPs to reflect critically on their clinical practice, focus on their practice facilities and management, and stay in touch with developments in dental education. Through their visits and assignments, students gained skills in observation, interviewing, communication, relation-building and report writing. CONCLUSIONS: Placements of dental undergraduates in general dental practices enable students to gain insight into the GDS, develop key transferable skills and undergo professional socialisation. They are also beneficial and enjoyable for the GDPs who participated.

Perceived inability to cope and care-seeking in patients with toothache: a qualitative study.

AIMS: To explore the subjective experience of a sample of patients attending a dental teaching hospital emergency clinic with toothache. MATERIALS AND METHODS: Subjects 21 female and 14 male dental patients, of different ages, marital status, employment status and levels of education, presenting with toothache at a dental teaching hospital emergency clinic. Data collection Unstructured in-depth interviews, following a topic guide. Analysis Transcribing, sifting, indexing and charting data according to key issues and themes. FINDINGS: A dimension of toothache pain that emerged was the perceived inability to cope. Patients reported a dependency on a dentist or other person to alleviate their pain, suggesting connotations of helplessness, disempowerment and incapacitation. The perceived inability to cope was also expressed in terms of loss of control, despair and isolation. A number of care-seeking patterns for toothache was identified: repeated visits to the same dentist for emergency care, repeated visits to different dentists, attendance at the dental hospital emergency clinic and consulting non-dental health workers such as doctors and pharmacists. CONCLUSIONS: The perceived inability to cope and care-seeking patterns are two unexplored dimensions of the toothache pain experience. Both dimensions may be associated with pain intensity, the clinical conditions that manifest as toothache, quality of treatment provided and management of demand for emergency dental care. A conceptual framework is proposed for future research to investigate these relationships.

Dental students' evaluation of 2 community-oriented PBL modules.

OBJECTIVES: To evaluate dental students' perception of 2 problem-based learning (PBL) modules in Dental Public Health implemented within the context of a traditional formal curriculum. METHODS: 2 dental community modules were implemented with an 8-month interval between them on the same group of dental undergraduates; the first in Term 2 and the second in Term 4 of a 5-year 15-term dental course. At the end of each module, a semi-structured questionnaire was administered to evaluate the introductory lecture, the fieldwork activity and the organisation of the modules. RESULTS: In both modules, students reported gaining insight into the subject matter, skills in teamwork, making presentations and collecting data. Some students in the 1st module needed more time to fulfil their learning objectives and had difficulty in collecting data. In the 2nd module, students reported that they lacked motivation because of the place of the module within their timetable. Opinions differed about groupwork. The content of and interest generated by fieldwork activity was rated more positively in the 2nd module than the 1st. Less positively rated in the 2nd module was the introductory lecture and module organisation. CONCLUSIONS: Implementing PBL within a traditional curriculum does not offer uniform outcomes for students. Optimum group size and adequate time are necessary if students are to benefit from PBL. A consistent and continuous PBL approach should be adopted rather than a sporadic one. Further research should establish the optimum balance between PBL and traditional approaches that would allow students to maximise the benefits of both and to identify those students best equipped to benefit from a 'mixed economy' of learning.

Oral health knowledge, beliefs and practices of a sample of Chinese elders in Inner London, UK, aged 54 years and over: a pilot investigation.

OBJECTIVES: To explore the self-reported oral health and health behaviours of a sample of Inner London Chinese elders and the impact of their self-reported oral health on their social functioning and eating ability. DESIGN: Cross sectional. SETTING: Luncheon clubs in Central and East London, UK. SUBJECTS: 54 Chinese elders aged 54-81 years. INTERVENTION: A structured questionnaire, administered by two interviewers in Cantonese. MAIN OUTCOME MEASURES: Knowledge and beliefs about the causes and prevention of tooth decay and gum disease, the oral conditions experienced in the previous twelve months and the impact of these conditions. RESULTS: Overall health was rated more positively than oral health, although those who reported below average oral health were more likely to report below average overall health. Whilst over half thought that sugar and sweet food could cause tooth decay, only 19% thought that poor oral hygiene could cause gum disease. Over half thought that "hot air" caused gum disease. Three quarters brushed their teeth at least twice a day. Two thirds had experienced at least one oral condition in the previous twelve months, with the more elderly being more likely to report this. Social impacts affected 41% of the sample whilst 44% suffered at least one dietary impact. CONCLUSIONS: The burden of oral conditions is substantial, especially on the more elderly members, impacting on the performance of social functions. These burdens indicate a need for oral health services. Beliefs in the traditional Chinese explanation of "hot air" as a cause of gum disease were common. Health promotion effort should consider these when developing health messages.

Active immunization in HIV-infected patients.

Patients infected with human immunodeficiency virus (HIV) are at risk for various viral and bacterial infections. Active immunization with currently available vaccines may reduce the risk of some vaccine-preventable diseases in this population. Based on available data, most vaccines used in the United States are safe in HIV-infected adults and children. Their clinical efficacy in these individuals is not well defined, although it appears that patients in the earlier stages of infection are more likely to mount a protective antibody response than those in the later stages. Current guidelines for vaccination in HIV-infected children and adults in the United States have been recommended by the Advisory Committee on Immunization Practices.

Management of cytomegalovirus infection in patients with acquired immunodeficiency syndrome.

The clinical manifestations of cytomegalovirus (CMV) infection in persons with AIDS are described, and recent advances in the management of these syndromes with antiviral agents are reviewed. CMV infection is the most common serious opportunistic viral infection in AIDS patients. Clinical manifestations include chorioretinitis, gastroenteritis, hepatitis, pneumonia, CNS infection, adrenalitis, and a wasting syndrome. The diagnosis of CMV infection requires laboratory demonstration of a serologic response to the virus, detection of viral components or products, or isolation of the virus. Ganciclovir is an acyclic nucleoside analogue marketed for the treatment of CMV-related retinitis in immunocompromised hosts. After i.v. ganciclovir induction therapy, more than 80% of patients show improvement or stabilization of retinitis. Relapse is common in AIDS patients, however, and low-dose i.v. maintenance therapy is recommended. The most serious dose-limiting effect is neutropenia. Intravitreal injection of ganciclovir has been well tolerated and efficacious. Ganciclovir has shown some efficacy in the treatment of other life-threatening CMV infections, especially gastroenteritis, but data are limited. Ganciclovir-resistant strains have been reported. Foscarnet, a pyrophosphate analogue with activity against both human CMV and human immunodeficiency virus, is undergoing clinical trials. Foscarnet has shown promise in the therapy of CMV-related retinitis, but results for other CMV infections are disappointing. Nephrotoxicity is the major dose-limiting effect. AIDS patients with sight-threatening and rapidly progressive CMV-related retinitis should be treated with ganciclovir. Foscarnet may offer an alternative when it becomes available. More must be learned about the efficacy of these drugs in the treatment of CMV infection in patients with AIDS.

Drug allergy documentation by physicians, nurses, and medical students.

The completeness and accuracy of drug allergy documentation by medical residents, medical students, and primary-care nurses in a 450-bed teaching hospital were assessed, along with patients' knowledge of their drug allergy status. During a three-month period, the current admission notes written by medical residents, medical students, and primary-care nurses for adult medicine patients with drug allergies were reviewed by a pharmacy student. Patients with drug allergies were identified by the presence of drug hypersensitivity labels on the front of the medical charts. The student collected information about each reaction and determined whether it was a true allergic reaction, a nonallergic adverse reaction, or unclassifiable. A second pharmacy student interviewed the same patients whose medical charts had been reviewed and asked seven open-ended questions about the allergy status of each patient. For the 49 patients included in the study, 75 drugs were listed as allergens on the front of the patients' charts and 78 drugs were reported as allergens during patient interviews; only 66 of those drugs were identified both on the charts and by the patients. Approximately 20% of the health-care professionals failed to document the drug allergies in their admission notes. Although the majority of patients could recall the dosage form of the offending drug, the time that had elapsed between administration of the drug and appearance of symptoms, and how long ago the reaction had occurred, none of this information was recorded by the health-care professionals. Incomplete documentation of the drug allergy status of patients in our hospital does not appear to be related to patients' inability to provide accurate information.

Severe thrombocytopenia associated with once-daily rifampin therapy.

Rifampin-induced thrombocytopenia has been recognized as an immunological reaction associated with intermittent high-dose therapy, and rarely seen with daily low-dose regimens. Our patient was a 33-year-old male with Marfan's syndrome who was given rifampin 600 mg/d po along with intravenous vancomycin for the treatment of Staphylococcus epidermidis endocarditis. His platelet count dropped from a baseline of 519,000/mm3 to 4000/mm3 after four doses of rifampin. Petechiae were present on the lower extremities without the presence of other bleeding sites. Rifampin, low-dose aspirin, and dipyridamole were discontinued. His platelet count returned to normal nine days after discontinuation of therapy. With the increasing use of rifampin for the treatment of nontuberculosis infections, clinicians should recognize the possibility of this drug causing such serious immunological reactions as thrombocytopenia, hemolytic anemia, acute renal failure, and shock with daily or intermittent therapy.