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Breast cancer and HIV: a single institution review of a non-AIDS defining cancer in women in the setting of high HIV prevalence
No full textBACKGROUND
The prevalence of HIV infection is high in sub Saharan Africa. However the impact of this high prevalence on breast cancer incidence, pathogenesis, age, stage at presentation, treatment response and toxicity in the HIV infected and uninfected female remains unknown.
OBJECTIVES
The study sought to characterise breast cancer in patients with a known HIV status as well as compare treatment tolerability and outcomes in HIV determinate and indeterminate patients.
METHODS
A search through the case notes of 382 patients with a diagnosis of breast cancer diagnosed between January 2008 and December 2011 was carried out to identify female patients with an HIV test result .Data collected from these patients included age at cancer diagnosis, demographics, breast cancer and HIV risk factors, histology, stage, CD4 count and use of antiretroviral drugs in HIV positive patients, treatment, toxicity and outcome.
RESULTS
A total of 92 patients were identified, 67 HIV negative and 25 HIV positive. All patients were black African. Median age at diagnosis was 42 (Range 34 to 58) for the HIV positive and 50 (Range 30 to 88) for the HIV negative patients. Median CD4 at breast cancer diagnosis was 440cells/microlitre and median known duration with HIV was 3 years for the HIV infected patients. Mode of HIV infection was confirmed heterosexual transmission in 2 patients. Seventy two percent of HIV positive patients were receiving non protease inhibitor antiretroviral drug regimens. There was no difference in presentation and pathologic features between the HIV negative and positive patients. None of the patients had a history of prior screening. All stages of breast cancer were seen with the majority of the patients presenting with advanced stage disease with no statistically significant differences in stage at presentation between the HIV positive and negative patients. Hormone receptor and Her 2 neu status was available for a total of 21/92(22.8%) patients, with 3/17(17.7%) HIV negative and1/4(25%) HIV positive patients being triple negative. HIV positive patients were more likely to have ER and PR negative and HER2 neu positive breast cancer with HIV negative patients more likely to have ER and PR positive and HER 2 neu negative disease and this difference was statistically significant. Choice of chemotherapy was not determined by HIV status in these patients. Myelosuppression was present in both HIV negative and positive patients during chemotherapy but was more pronounced in the HIV positive patients. Two of the latter had progression of HIV on treatment manifested by development
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of an opportunistic infection on treatment. Radiotherapy was well tolerated in both the HIV positive and negative patients. Default to follow up was high in this cohort.
CONCLUSIONS
This study suggested that whilst there was no difference in histology and stage at presentation, the natural history of breast cancer in the setting of HIV infection was worse than in the HIV uninfected patient with younger age at presentation, poor prognostic tumour biology and poor treatment tolerability. Chemotherapy for breast cancer also had an adverse impact on the natural history of HIV infection. HIV infection and immunosuppresion did not appear to have a permissive role in breast cancer development. Although the incidence of breast cancer is not increased in HIV positive women, the high prevalence of the two diseases in our population makes their coexistence in the same patient more probable.This work was supported by Grant number 5U2RTW007367 from the Forgarty International Centre, National Institutes of Health (NIH, USA) through the International Clinical, Operational and Health Services and Training Award (ICOHRTA
Comparative evaluation and assessment of the diagnostic usefulness of four commercial HIV-l/HIV-2 antibody assays using two well-characterized serum panels from Blood Transfusion Service and the National Health Laboratory services in Zimbabwe
No full textObjective: To evaluate four Enzyme Linked Immunosorbent Assay ( ELISA) HIV kits for possible use as a combination at the National Health Laboratory Services (NHLS) in Zimbabwe. Design: Laboratory evaluation, sensitivity, specificity and cost effectiveness of HIV diagnostic kits. Setting: Blood Transfusion Service (BTS) and Parirenyatwa Hospital in Zimbabwe. Subjects: A total of 346 samples from 245 patients referred to Parirenyatwa Hospital and 101 blood donors at BTS. Main outcome: The main goal was to come out with the best combination of ELISA kits in terms of sensitivity, specificity and cost effectiveness for use in diagnosis of HIV infection in Zimbabwe. Results: The best combination kit was the Murex/Innotest with 100% sensitivity and 98.9% specificity, being slightly superior to the Genelavia/Vironostika combination kits in current use at NHLS. In addition, the Murex/Innotest combination has the shortest assay running time and requires fewer internal controls thereby increasing the number of test specimens per run. Conclusion: We recommend the use of the Murex/Innotest kits as a suitable combination for HIV infection diagnosis in Zimbabwe. The combination has a relatively low number of discordant results, drastically reducing the cost of running a third confirmatory test to resolve the discordant results. Most importantly, this combination maximizes HIV infection diagnosis by its ability to detect antibodies to HIV-1 groups M and O as well as HIV--2
Pharmacogenomics: today, tomorrow and beyond
No full textPharmacogenomics is today’s hot topic in biotechnology. In 1996 the word did not even exist; now international pharmacogenomics meetings are held monthly, and articles appear weekly in scientific journals ind the popular press. In this Viewpoint article, we will discuss what pharmacogenomics is and elaborate on vhat the impact of pharmacogenomics will be on medical practice in the next few years and further in the future
Relationship between self-care practices and readmissions among adults aged 40-80 years with chronic heart failure at a Central Hospital In Zimbabwe
No full textReadmissions for chronic heart failure are a major concern for medical surgical nursing and can be preventable in at least 40% of the cases (Robert & Bowling, 2001). Self-care practices could influence outcomes of chronic heart failure patients such as readmissions (Lee, 2009). The purpose of this study was to describe as well as examine the relationship between self-care practices and readmission among chronic heart failure patients. The theoretical model used to guide this study was Orem’s self-care model. A non-experimental descriptive correlational study design was used. A simple random sample of 65 adults aged 40 to 80 years with chronic heart failure was selected from the outpatients’ clinics. An instrument comprising of 3 sections namely the demographic data section, the readmissions section (RS) and the chronic heart failure self-care practices section (CHFSCP) was administered using the face-to-face interview technique. The relationship of self-care practices and readmissions was analysed using the inferential statistics. Data was analysed using the Statistical Package for Social Sciences (SPSS). There was a negative linear relationship between the independent and the dependent variables (r=-.436, p<.01). This means that as self-care practices improve, the number of readmissions decreases. The effect of the independent variable on the dependent variable as indicated by R²=.191 (F=14.828, p<.01). This meant that self-care practices explained 19% of the variance observed in the readmissions. The mean score for the chronic heart failure self-care practices section was 46.5 and 33(50.8%) subjects had total scores below this mean. Medical surgical nursing practice should adopt protocols that support good self-care practices and the protocols should take an individualized approach to maximize reduction of readmissions among chronic heart failure patients
Factors influencing treatment failure in HIV positive adult patients on first line antiretroviral therapy
No full textBackground: Risk factors for treatment failure in HIV positive adults have not been studied extensively in Zimbabwe.
Aim: To investigate socio-demographic, psychosocial and antiretroviral drug related factors as possible risk factors for treatment failure.
Objective: To compare the accuracy and reliability of CD4 count results in diagnosing treatment failure versus viral load results.
Design: Adescriptive cross-sectional survey.
Setting: Harare Central Hospital adult opportunistic infections clinic.
Participants: One hundred and eighteen (118) HIV positive participants on Is' line antiretroviral therapy (any 1 of stavudine, tenofovir or zidovuume combined with lamivudine and nevirapine or efavirenz) for at least 1 year. Participants were conveniently sampled.
Main Outcome Measures: First line treatment failure as defined according to World Health Organisation (WHO) 2010 guidelines.
Results: Factors associated with higher odds of treatment failure were severe depression [OR 3.7; p-value 0.002; 95% Cl 1.6-8.5] and discontinuing ART [OR 4.4; p-value 0.02; 95% Cl 1.3-14.7], Factors associated with lower odds of treatment failure were age =42 [OR 0.3; p-value 0.007; 95% Cl 0.1-0.7], taking ART on time [OR 0.2; p-value 0.02; 95% Cl 0.05-0.8], time on ART >4 years [OR 0.6; p-value 0.02; 95% Cl 0.3-0.9] and female sex [OR 0.4; p-value 0.02; 95% Cl 0.2-0.8], There was statistically significant difference between CD4 count and viral load results in diagnosing treatment failure [OR 8.7; p-value 0.0005; 95% Cl 3.6-21.2], Conclusion: Severe depression and discontinuing ART predisposed to treatment failure. CD4 counts were not as reliable as viral load measurements in diagnosing treatment failure
The impact of time taken from referral to admission into the intensive care unit on mortality and duration of admission
No full textThis study investigated the effect of time taken from patient referral to ICU to the admission time and its effect on patient mortality and length of stay.
Methods
A prospective descriptive study of emergency medical and surgical patients admitted into the adult ICU at Parirenyatwa and Harare central hospitals between the months of February 2014- June 2014. Patients for whom an ICU bed was requested were followed up from the date and time they were referred to the date and time of admission. Further follow up of the length of stay and mortality was done. Delay was defined as a lead time of at least 4 hours and was compared with patients admitted within 4 hours of referral. Confounding variables examined were sex, National Early Warning System Score (NEWS), and age.
Results
A total of 128 patients participated in this study, 48% were delayed by more than 4 hours
from referral to admission whilst 52% were admitted within 4 hours with an average lead- time of 7.5 hours and more male patients were delayed by >4 hours(63% =0.003). Patients delayed for more than 4 hours had a higher mortality (22.9%) compared to those admitted within 4 hours (18.3%). There was no significant effect of lead time to length of stay in ICU.
Conclusion
There is an association between time taken from referral to admission and mortality. Earlier ICU admission will lead more likely to better mortality rates in ICU
An audit of clinical assessments of low back pain conditions managed at Parirenyatwa hospital’s rehabilitation department: 2 year retrospective study (2010-11)
No full textand Aim: Musculoskeletal conditions contributed 62% of all the cases that presented to Parirenyatwa Hospital’s Physiotherapy Outpatient Department during the year 2010-11. Low back pain contributed 13% of these musculoskeletal conditions. Although assessment forms are available at Parirenyatwa, Physiotherapists do not use these preferring to a “helicopter” type of assessment which does not cover all areas of low back pain assessment. This lead the author to investigate the adequacy of such assessments.
Methods: A retrospective audit study was carried out on assessment forms used for patients presenting with LBP conditions at Parirenyatwa Hospital’s Physiotherapy Department during 2010-11. A Chartered Society of Physiotherapy (CSP) pro forma was utilized for auditing the records. In addition a focus group discussion (FGD) was carried out with Physiotherapists working at Parirenyatwa. Data were entered into EPI info version 3.5.3 and descriptive statistics used to obtain the frequencies, graphs and tables.
Results: A total of 86 assessment forms of patients presenting with low back pain conditions were audited. The most assessed areas under subjective assessment were social and family history (97.7%), presenting condition (96%), past medical history (89.5%), current medications (79.1%), investigations (60.5%) and the least documented were precautions (2.3%), patient’s perceptions (0%) and expectations (0%). The most assessed areas under objective assessment were palpation (81.4%), observation (66.5%), problems (66.3%), and the least documented was impression of clinical diagnosis (7%), and result of outcome measurement (7%). Results of the FGD were that:- clinical supervision, continuous professional development, staff shortage, clinical judgment, work experience, attitude and competence all contributed to what areas were assessed.
Conclusion and Recommendation: A “helicopter” assessment leads to inadequate assessment as shown by the results for example patient’s perception and expectations were not addressed, therefore it is necessary to audit assessment forms at regular intervals to ensure quality care.Ministry of Health and Child Welfar
Outcome of stavudine induced peripheral neuropathy in HIV-1 positive patients switched or substituted to a non-stavudine-based regimen
No full textA study to assess the outcome of Stavudine induced peripheral neuropathy in HIV – 1 positive patients switched or substituted to a non-Stavudine-based regimen.
Background : Stavudine is used in combination with other antiretroviral agents for the treatment of HIV- 1 infection . Among several serious complications it can cause a potentially crippling peripheral neuropathy. It is for this reason that it is no longer considered an appropriate drug of choice in any antiretroviral regimen in developed and more recently developing countries. A study to assess the prevalence as well as the outcome of Stavudine induced peripheral neuropathy in individuals who are no longer on the drug has not been previously described in this setting.
Objective : To determine the outcome of Stavudine induced peripheral neuropathy following its discontinuation.
Methodology : Peripheral neuropathy was defined using the ACTG Brief Peripheral Neuropathy Score which requires the presence of at least one symptom of peripheral neuropathy plus one objective abnormal examination finding.
Study Design : A cross- sectional study of 385 participants performed over 10 months at Parirenyatwa Hospital Opportunistic Infections Clinic in Harare, Zimbabwe.
Subjects : Consenting adults aged 18 yrs and above , who were on a Stavudine-based regimen for at least one month prior to switch to a non-Stavudine-based regimen.
Primary outcome measures : The proportion of patients with persistent peripheral neuropathy following cessation of Stavudine as determined by the ACTG Brief Peripheral Neuropathy Score.
Secondary outcome measures : Demographic and clinical factors associated with persistence of symptoms of Stavudine induced peripheral neuropathy following cessation.
Results : A total of 385 participants were recruited into the study. Out of these (256)66.5% were female. The mean age, weight and height were 42.7 ± 11.7 yrs, 69.3 ± 14.8 kg and 163.7 ± 8.83 cm respectively. The median duration on Stavudine was 39 months (IQR 19.5-63). The median duration off Stavudine was 23 months (IQR 12.5-36.5). Out of the total number of participants, 45.19% had ongoing Stavudine induced peripheral neuropathy. Stavudine induced peripheral neuropathy was strongly associated with a low CD4+ count, concurrent hypertension as well as tuberculosis therapy (OR -2.69-[95% CI 1.61-4.48;p=0.0001],2.98-[95% CI 1.66-5.35;p=0.0002] and 7.03-[95%CI 0.84-58.99;p=0.037]) respectively. Individuals exposed to Stavudine for longer than 24 months were 46% less likely to develop peripheral neuropathy. (OR - 0.54-[0.35-0.82;p=0.004])
Conclusion : Stavudine induced peripheral neuropathy persists in a significant subgroup of patients after cessation of use. Its continued use as part of any antiretroviral regimen should therefore be discouraged. Identification of such patients following cessation of therapy with a simple screening tool will allow targeted early treatment to prevent further progression of peripheral neuropathy.The International Clinical, Operational and Health Services Research and Training Award For TB/HIV (ICOHRTA
Investigation of the effect of stalanev (Stavudine, Lamivudine and Nevirapine) treatment on plasma lactate levels in adults attending Beatrice Road and Wilkins Infectious Diseases Hospital Opportunistic Infections clinics in Harare, Zimbabwe
No full textMain Objective: To evaluate the effect of Stalanev (Stavudine, Lamivudine and Nevirapine) treatment on plasma lactate levels in adults attending Beatrice Road Infectious Diseases Hospital and Wilkins Infectious Diseases Hospital Opportunistic Infections Clinics in Harare,
Design: Prospective cohort study carried out between January and May 2011
Setting: Beatrice Road and Wilkins Infectious Diseases Hospital Opportunistic Infections Clinics in Harare, Zimbabwe.
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Metabolic effects of carbon dioxide insufflation during laparoscopic surgery: Changes in pH, arterial partial pressure of carbon dioxide (PaCO2) and end tidal carbon dioxide (EtCO2).
No full textPurpose: The purpose of this study was to assess the effects of low tidal volume ventilation
on patients undergoing laparoscopic surgery on partial pressure of carbon dioxide, arterial
to end tidal carbon dioxide gradient and acid base excess.
Methods: 30 patients undergoing laparoscopic surgery under General Anaesthesia were
ventilated with tidal volume of 6 ml/kg and respiratory rate of 12breaths/minute and End
tidal C02, PaC02, pH, Bicarbonate and ABE measurement was done before, during and after
C02 pneumoperitoneum and analyzed. Respiratory adjustments were done for End tidal CO2
levels above 60mmHg or haemodynamic changes attributable to elevated CO2.
Results: Pneumoperitoneum resulted in a significant elevation in PaCO2 (p<0.001) and a
fall of pH (p <0.001), ion bicarbonate (p = 0.011), and base excess (p <0.001). A correlation
was found between the EtCO2 and PaCO2 during pneumoperitoneum. No ventilatory
adjustments were instituted on any of the patients as they maintained EtCO2 below 60mmHg
throughout pneumoperitoneum.
Conclusion: Besides the expected respiratory acidosis, a metabolic acidosis can also be
present during pneumoperitoneum. EtCO2 is still a good non invasive monitor for estimation
of PaCO2 during low tidal volume ventilation during pneumoperitoneum.NECTA