Human immunodeficiency virus infection in Haiti.

This article reviews human immunodeficiency virus (HIV) infection in Haiti. The evolution of the epidemic in Haiti, its spread from urban to rural areas, its varied clinical manifestations, and the attitudes of Haitian people toward HIV infection provide important lessons on understanding and managing this infection in a developing country. The heterosexual spread of HIV, particularly among the poor, is well-documented as is the role of other sexually transmitted diseases along with tuberculosis. Coinfection of HIV and tuberculosis have led researchers to study the effects of six-month supervised intermittent tuberculosis therapy both in controlling tuberculosis and slowing the progression of HIV. Various surveys and discussion groups about acquired immunodeficiency virus knowledge and beliefs demonstrate a large deficit in HIV education despite campaigns to educate the population. The great impact of HIV disease on morbidity and mortality in Haiti indicates that a great deal of work still needs to be accomplished and demonstrates the frustration in fighting the infection in countries with inadequate resources and infrastructure. Advances in HIV vaccine research seem to be the most promising option for developing countries such as Haiti.

Socioeconomic influences on the transmission of human immunodeficiency virus infection: the hidden risk.

Worldwide, and in pockets of poverty in the United States, there is growing evidence that poverty is a major contributor to the spread of human immunodeficiency virus infection. Specific socioeconomic forces contributing to the spread of the infection include the status of women, prostitution, drug use in poor populations, the role of prisons, economic factors that disrupt families, and cultural attitudes. A lack of awareness of or an unwillingness to address the social, cultural, and economic forces contributing to the transmission of the human immunodeficiency virus have hampered attempts to stem the epidemic. A "social prevention" strategy is called for in which socioeconomic influences on human immunodeficiency virus transmission can be ameliorated. Practicing physicians should be aware of these forces because they profoundly influence the effectiveness of patient education, prevention, and treatment.

Resolving the conflicts between general and subspecialty medicine: the internist as consulting physician-scientist.

Internal medicine is confronting a conflict between its generalist and specialty roles, coupled with a conflict between the needs of academic internal medicine in contrast to those of private practice. The historical origins of these conflicts are explored. To resolve these conflicts, internal medicine must rediscover the common ground shared by the general internist and specialist, academician and practitioner. This common ground is best found in the role of internist as physician-scientist. In the future, specialists and general internists will need to emphasize their roles as consultants. In the process, internal medicine will become smaller and more "academic." The benefits of this role for internal medicine should be rapidly demonstrated through outcomes based research in order to win over skeptical payors, peers, and the public at large.

Intracellular starvation in the insulin resistance syndrome and type II diabetes mellitus.

Statistical associations of insulin resistance, type II diabetes, hypertension and hyperlipidemia have been well documented, but the pathophysiology of the 'insulin resistance syndrome' is unknown. This article explores the hypothesis that intracellular starvation plays a central role in the development of type II diabetes, hypertension and hyperlipidemia. According to this hypothesis, insulin resistance leads to inadequate intracellular glucose, which in turn leads to insufficient amounts of adenosine triphosphate needed for ion transfer, and to drive energy-requiring reactions. Indirect evidence supporting this hypothesis is presented. Intracellular starvation is also discussed as an alternative to the 'glucose hypothesis' to explain certain complications of diabetes.

The health care delivery crisis in Haiti.

BACKGROUND AND OBJECTIVES: This article documents the history, politics, and economics that have contributed to a health care delivery crisis in Haiti and why family medicine will be crucial for the recovery of Haiti's health care. Since the United Nations intervention, there has been some improvement in health conditions. However, the embargo and political turmoil left little infrastructure on which to build. Developing family medicine, one of the priorities of the Ministry of Health, will reverse traditional forces that favor emigration and specialization and will provide the country with well-trained physicians who can treat most of the common health problems of Haiti. These common preventable and treatable problems are now contributing to short life expectancy and high infant mortality. While the ultimate responsibility for Haiti's health rests with Haitian health professionals, the country has an immediate need for international humanitarian assistance, particularly for general medical care.

PIP: With its 7 million people inhabiting an area the size of the state of New Jersey and with average annual per capita income of $225, Haiti is the poorest and most densely populated country in the Western Hemisphere. 85% of children in rural Haiti have clinical evidence of malnutrition, the infant mortality rate is 94/1000 live births, the maternal mortality rate is 4.5/1000 live births, life expectancy is 55 years, and there are rapidly growing rates of tuberculosis, malaria, and AIDS. Much of Haiti's health crisis is tied to the country's recent troubled political and economic past. That past has disrupted Haiti's health infrastructure to such an extent that Haitian people routinely suffer with, and often die from, readily preventable and treatable illnesses. Haiti's health care infrastructure cannot be rebuilt without humanitarian support and technical assistance from the international community. The authors explain the history, politics, and economics which have contributed to the health care delivery crisis in Haiti and why family medicine will be crucial for the recovery of the country's health care. The development of family medicine will check certain elements which favor emigration and specialization, and will provide the country with well-trained physicians who can treat most common health problems in the country.

The degree of blood pressure evaluation and end organ damage with severe hypertension: a case-control study.

To investigate the association of blood pressure and end-organ damage in patients with severe hypertension in a case-controlled manner, 26 patients with syndromes of acute end-organ damage and severe hypertension were compared with 25 patients with severe but asymptomatic hypertension for a variety of demographic, clinical, and basic laboratory values. Differences were assessed with the Chi-square test and multiple logistic regression analysis. End-organ damage was significantly associated with a degree of systolic and diastolic blood pressure elevation, a history of hypertensive crisis, serum creatinine, and a history of alcohol use, in multivariate analysis. The relationship to creatinine and a history of hypertensive crisis were not present in univariate analysis. The possible relationships of these factors to the pathophysiology of hypertensive crisis are discussed.

Lessons from a clinic for the homeless. The Camillus Health Concern.

OBJECTIVE: To present the educational opportunities provided by a model clinic for homeless persons. DESIGN: Descriptive. PATIENTS OR OTHER PARTICIPANTS: Patients are those who are cared for at Camillus Health Concern clinic for the homeless in Miami, Fla. Other participants include students, residents, and faculty affiliated with the University of Miami (Fla) School of Medicine. INTERVENTION: Affiliation of the clinic with the medical school has shifted the clinic from a pure service model to an education and service model. MAIN OUTCOME MEASURES: Numbers of patients and encounters are presented, as well as student and resident rotations, numbers, and hours. RESULTS: Shifting to an education and service model has increased productivity of the clinic while providing a unique, multifaceted educational experience to students, residents, and faculty. CONCLUSIONS: Those factors that contribute to the success of this education and service model include the professional satisfaction that results from providing care to patients who previously have not had access to health care; a team approach that includes faculty, students, nurses, and social workers; an environment that fosters clinical judgment rather than expensive tests; and the opportunity to teach social responsibility in the process of providing health care. We encourage other schools to consider the development of clinics for the homeless as alternative ambulatory training sites.

The relationship of total lymphocyte count to CD4 lymphocyte counts in patients infected with human immunodeficiency virus.

A simple, inexpensive alternative to CD4 counts would facilitate the management of asymptomatic and early symptomatic patients with HIV infection. In this report, a high correlation was found between CD4 counts and total lymphocyte counts calculated from complete blood counts in a cohort of ambulatory HIV-infected patients. Using these data, patients with CD4 counts above and below 500 cells/mm3, 200 cells/mm3, and those with and without symptoms can be identified with a high degree of predictive value. The availability and lower cost of lymphocyte counts make them an attractive alternative to CD4 counts in managing asymptomatic and early symptomatic patients with HIV infection.

Increased oxidative metabolism in PMA-activated lymphocytes: a flow cytometric study.

Flow cytometry and the fluorescent dyes DCF and R123 were used to examine oxygen metabolite production in human leukocytes and T-lymphoblastoid Jurkat cells, activated by PMA or by FMLP. When unseparated leukocytes were activated by PMA, oxidative products were generated not only in PMN and monocytes but also to a lower extent in lymphocytes. These responses were correlated with protein kinase C activation. PMA did not, however, induce the synthesis of reactive oxygen species in isolated lymphocytes. FMLP did not affect lymphocyte oxidative metabolism when added to the whole leukocyte mixture, but activated only the phagocyte populations. Similarly, Jurkat cells which alone were unresponsive to PMA, became strongly fluorescent when they were mixed with PMN and treated with this activator. In all cases, they did not respond to FMLP. Superoxide dismutase and catalase addition did not prevent the lymphoid cell response in the presence of phagocytes, whereas Desferal did. These data indicate that under physiological conditions, activated lymphocytes are capable of oxidative metabolism and also evidence some close relation between the leukocyte populations. We discuss the putative mechanism of oxygen metabolite generation in lymphocytes and the role of these metabolites in the immune response.

Courvoisier's sign revisited: two patients with palpable gallbladder.

More than a century ago, Courvoisier published his observation on the significance of a palpable gallbladder in the differential diagnosis of obstructive jaundice. We have described two patients with newly described conditions--AIDS-associated cholangiopathy and diet-induced cholecystitis--who had a palpable gallbladder and have discussed possible pathogenetic mechanisms.