RSS 1.0Physical Health
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Lipid disorders in HIV patients: what about raised HDL-cholesterol?No abstract available
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A Commentary on Lipid Disorder and HDL-Cholesterol in HIV Patients: Changing TrendsWith the advent of highly active antiretroviral therapy (HAART) there have been remarkable improvements in the survival of HIV patients. However, complications in the form of dyslipidaemia, insulin resistance, bone problems and liver and kidney disorders have been found to be more noticeable compared to AIDS defining illnesses. The continuous exposures of antivirals of different class with different side effects profile have led to a new trend of problems.
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The Effect of Low Dose Oral Vitamin D on Bone Mineral Density Changes in HIV Patients: 36 Months Follow UpBackground: A high incidence of vitamin-D deficiency and abnormal bone mineral density (BMD) is reported among Human Immunodeficiency Virus (HIV) infected patients. The study highlighted the effect of oral low dose vitamin-D replacement in patients with a known vitamin- D deficiency on the levels of vitamin-D [25 (OH)D], parathyroid hormone (PTH) and Bone Mineral Density (BMD) of hip and spine. Methods: Patients took a daily low dose of 800IU of vitamin-D. The following details were collected on all patients: demographics, CD-4 cell count, viral load, fracture risk factors, treatment history, corrected calcium, alkaline phosphatase (ALP), Parathyroid Hormone (PTH) (intact PTH), vitamin D 25(OH)D, inorganic phosphate and BMD of hip and spine at baseline, 12 and 36 months. Results: Our Cohort consisted of 86 patients. Patient details included: mean age 42.8 (+/-7.7) years, 48 (55%) females 64, (74%) black African, CD-4 count 440.7 (+/-180.8) cells/dL, plasma VL 1.6 log (+/-2.3) copies/mL, duration of illness 80.9 (34.1) months, duration of exposure to antiretroviral 65.2 (+/-27.9) months. At baseline, no difference in BMD of hip or spine was observed, however, a higher PTH (0.001) in patients taking Tenofivir and a lower vitamin-D was noticed in patients taking Efavirenz. After 36 months, patients on vitamin D replacement (n=44) had a significant increase in vitamin- D level (15.4 +/-10.4 vs 104.1+/-29.1 p=0.0001), lower PTH (6.3 +/-3.4 vs 4.4 +/-1.4 p=0.0001) ALP (108.9+/-78.8 vs 90.6+/-45.8 p=0.05) but no change in corrected calcium (2.13 +/-0.1 vs 2.16 +/-0.34 p=0.5) and BMD of spine (1.039+/-0.226 vs.1.027+/-0.211, p=0.77), and BMD of hip (1.020 +/- 0.205 vs. 1.039, p=0.61). In a multivariate logistic regression analysis that included all significant variables, vitamin-D replacement independently was associated with increase in vitamin- D level (OR 2.08, CI 1.03, 4.12, p=0.005), decrease in PTH level (OR 0.53, CI 0.35, 0.82, p=0.04), but not with change in corrected calcium, alkaline phosphatase, BMD of hip or spine. Conclusion: After 36 months of follow up, the replacement of low dose once daily oral vitamin-D in the treatment experienced HIV infected patients with vitamin-D deficiency can increase vitamin- D level, reduce PTH level without any change in BMD of spine and hip.
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Malignancies Spectrum in the Era of Modern HAARTIn the current highly active antiretroviral therapy (HAART) era, studies suggest AIDS defining malignancies (ADM) are decreasing and non- AIDS defining malignancies (NADM) are increasing. We aimed to review all types of malignancies and risk factors in our HIV cohort over a period of ten years. Methods T his was a retrospective cohort study of all malignancy diagnoses and risk factors collected (2004-2014) from two teaching hospitals in the Midlands, United Kingdom. The demographic data and clinical features were collated and the primary end point of survival analysed. Secondary endpoints included risk factors for ADM compared to NADM. Results 111malignancy diagnoses 63 (54%) ADM and 48 (46%) NADM identified. Survival was worse once diagnosed with a NADM. About half of the ADM and a third of the NADM had a new HIV diagnosis at the same time or soon after the malignancy diagnosis. Haematological malignancies were the commonest malignancy in both groups. Oncogenic virus was an independent predictor of ADM risk . Conclusions Despite new and improved HAART regimens, ADM remain high in newly diagnosed HIV individuals and NADM are on the rise in those on longstanding HAART with stable HIV. Not only continuing HIV testing in new ADM as per the indicator conditions, but it is also important to increase HIV testing in new diagnoses of NADM such as all haematological malignancies and lung cancer.
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Charles Bonnet syndrome: an important differential diagnosis in new onset hallucinationsThe onset of new visual hallucinations in a patient with a longstanding history of bipolar disorder is extremely rare and when seen is often attributed to the pre-existing condition. A case of 73 year old male is presented here who developed new onset visual hallucinations on a background of stable mental health and was treated with multiple inpatient admissions and extensive antipsychotic therapy. He was later diagnosed to have Charles Bonnet Syndrome. Had visual loss been considered and treated earlier in the diagnostic process, the patient could have avoided the distress of these admissions, side effects of medication, radiation exposure from imaging and above all would have received appropriate treatment sooner. Furthermore, the Mental Health Services would have saved the cost of inpatient stay. It is therefore better to consider Charles Bonnet Syndrome as a differential diagnosis even in patients with well-established mental illness if they develop new onset visual hallucinations. This case report examines why the diagnosis of Charles Bonnet Syndrome can be missed, and its impact on geriatric patients.
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Assessment of the Impact of Schizophrenia on Healthcare Resource Use Among Patients with Cardiometabolic Conditions in England: Insights from Big Data AnalysisObjectives Having schizophrenia increases the risk of developing cardiometabolic conditions, increasing costs and complicating management. This retrospective cohort study among patients with cardiometabolic conditions in England aimed to determine the impact of comorbid schizophrenia on primary and secondary healthcare use, and on the costs of nonelective inpatient admissions, as well as whether this burden is influenced by the number of a patient’s cardiometabolic conditions. Methods Primary and secondary healthcare use data were collected from the Clinical Practice Research Datalink and Hospital Episode Statistics databases, respectively. Adults with ≥1 cardiometabolic condition(s) were grouped according to the conditions, and whether they had schizophrenia. Healthcare resource use, and costs of nonelective admissions were calculated for patient with/without schizophrenia and any, 1, 2, 3, or 4 cardiometabolic condition(s). Results were adjusted for age and sex. Abstract Results Patients with comorbid schizophrenia had 68% more GP appointments (18.09 versus 11.07 appointments/patient/ year), 19% more prescriptions (4.20 versus 5.06 prescriptions/ patient/year), 21% more outpatient appointments (7.94 versus 6.60 appointments/patient/year), 189% more A&E attendances (2.31 versus 0.80 attendances/patient/year), and 127% more nonelective inpatient admissions (1.69 versus 0.77 admissions/patient/year) than those without. The higher number of nonelective admissions represented £1,420.36 increased spending/patient/year, translating into a potential spend of more than £31M annually. Schizophrenia was associated with higher secondary care resource use after adjusting for the number of cardiometabolic conditions. Conclusions Among patients with cardiometabolic conditions, comorbid schizophrenia is associated with higher primary and secondary healthcare resource use and cost, even after adjusting for the number of cardiometabolic conditions.
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Anal incontinence following childbirth injury: The GP’s roleOne in five people who have a vaginal birth will develop anal incontinence in the 5 years following delivery. Many of them will suffer in silence, reluctant to raise the issue with healthcare professionals and unsure of where to turn to for help. Although an obstetric complication, it is a condition which often initially presents in primary care and is largely managed by GPs. The Ockenden review in 2022 found a significant lack of clinical training in postnatal care and GPs have reported a lack of confidence in supporting patients postnatally. Over the past decade, there has been a 3-fold increase in obstetric anal sphincter injuries. This article aims to raise awareness of anal incontinence post childbirth injury as a clinical issue and to encourage GPs to address this proactively within consultations. After reading this article, GPs should have improved confidence in managing this issue within primary care and an understanding of what resources are available to improve their clinical knowledge in this area.
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Audit on management of sexual assault victims attending an integrated sexual health service in CoventryThe management of victims of sexual assault need a holistic approach. The British Association of Sexual Health and HIV (BASHH) has set up standards for the management of sexual assault victims attending Sexual Health Clinics. We audited the management of victims of sexual assault attending an integrated sexual health service against recommendations from the latest BASHH guidelines. We included the recommendations and implementations already in place following an earlier audit in 2013 using the same guideline. Sixty-seven individuals identified themselves as victims of sexual assault. Most were of white ethnic origin (78%), female (96%) and the commonest age group was 18–25 years (39%). We achieved the 100% target in recording the date of assault, offering baseline sexually transmitted infection (STI) screening, HIV risk assessment, offer of post-exposure prophylaxis (PEP) for HIV where applicable and offer of emergency contraception. We were below the 100% target for other categories but improved compared to the previous audit except in recording the time when the first dose of PEP for HIV was given. The BASHH guideline has 14 auditable standards, all with a target of 100%. Our audit cycle completed in three years showed considerable improvement in achieving the standards in the management of Sexual Assault Victims. We hope this will encourage other centres audit their practice against the standards set by BASHH.
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An Intervention to Increase Condom Use Among Users of Chlamydia Self-Sampling Websites (Wrapped): Intervention Mapping and Think-Aloud StudyBackground: Young people aged 16-24 years are disproportionately affected by sexually transmitted infections (STIs). STIs can have serious health consequences for affected individuals and the estimated annual cost of treatment to the National Health Service is £620 million. Accordingly, the UK government has made reducing the rates of STIs among this group a priority. A missed opportunity to intervene to increase condom use is when young people obtain self-sampling kits for STIs via the internet. Objective: Our aim was to develop a theory-based tailored intervention to increase condom use for 16-24-years-olds accessing chlamydia self-sampling websites. Methods: The intervention, Wrapped, was developed using Intervention Mapping and was co-designed with young people. The following steps were performed: (1) identification of important determinants of condom use and evidence of their changeability using computer and digital interventions; (2) setting the intervention goal, performance objectives, and change objectives; (3) identification of Behavior Change Principles (BCPs) and practical strategies to target these determinants; and (4) development of intervention materials able to deliver the BCPs and practical strategies. Results: Users of existing chlamydia self-sampling websites are signposted to Wrapped after placing an order for a sampling kit. Salient barriers to condom use are identified by each user and relevant intervention components are allocated to target these. The components include the following: (1) a sample box of condoms, (2) an online condom distribution service, (3) a product for carrying condoms, (4) a condom demonstration video, (5) a series of videos on communication about condom use, and (6) erotic films of real couples discussing and demonstrating condom use. Conclusions: This intervention will be directed at young people who may be particularly receptive to messages and support for behavior change due to their testing status. Keywords: co-design; condoms; eHealth; internet; intervention development; sexual behavior; sexually transmitted infection; young adult.
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Vitamin D: Pharmacology and Clinical Challenges in Oral Health CareVitamin D is a hormone produced endogenously through cutaneous transformation of 7-dehydrocholesterol by UVB irradiation and exerts its effects through binding to its intracellular receptor. It has skeletal and non-skeletal functions and could be involved in oral health conditions especially periodontitis. In this review, we report the beneficial roles of vitamin D related to oral health. Vitamin D deficiency prevalence is high especially among the elderly and is associated with oral health complications such as periodontitis with a possible role and effects of vitamin D supplementation in the management of oral health conditions. Further research is needed to define vitamin D target levels and establish effective strategies for managing patients suffering from oral health conditions especially periodontitis. Improving the knowledge of dental practitioners, periodontists and pharmacists regarding vitamin D deficiency implications in oral health conditions could guide the management of oral conditions such as periodontitis.
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A visual antiretroviral regimen based tool to support cost-effective prescribing in treatment-naive individuals : defining the baselinePoster abstract P146 from the 23rd Annual Conference of the British HIV Association (BHIVA), Liverpool, UK, 4–7 April 2017.
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Dementia And Physical Activity (DAPA) trial of moderate to high intensity exercise training for people with dementia: randomised controlled trialObjective: To estimate the effect of a moderate to high intensity aerobic and strength exercise training programme on cognitive impairment and other outcomes in people with mild to moderate dementia. Design: Multicentre, pragmatic, investigator masked, randomised controlled trial. Setting: National Health Service primary care, community and memory services, dementia research registers, and voluntary sector providers in 15 English regions. Participants: 494 people with dementia: 329 were assigned to an aerobic and strength exercise programme and 165 were assigned to usual care. Random allocation was 2:1 in favour of the exercise arm. Interventions: Usual care plus four months of supervised exercise and support for ongoing physical activity, or usual care only. Interventions were delivered in community gym facilities and NHS premises. Main outcome measures: The primary outcome was score on the Alzheimer's disease assessment scale-cognitive subscale (ADAS-cog) at 12 months. Secondary outcomes included activities of daily living, neuropsychiatric symptoms, health related quality of life, and carer quality of life and burden. Physical fitness (including the six minute walk test) was measured in the exercise arm during the intervention. Results: The average age of participants was 77 (SD 7.9) years and 301/494 (61%) were men. By 12 months the mean ADAS-cog score had increased to 25.2 (SD 12.3) in the exercise arm and 23.8 (SD 10.4) in the usual care arm (adjusted between group difference -1.4, 95% confidence interval -2.6 to -0.2, P=0.03). This indicates greater cognitive impairment in the exercise group, although the average difference is small and clinical relevance uncertain. No differences were found in secondary outcomes or preplanned subgroup analyses by dementia type (Alzheimer's disease or other), severity of cognitive impairment, sex, and mobility. Compliance with exercise was good. Over 65% of participants (214/329) attended more than three quarters of scheduled sessions. Six minute walking distance improved over six weeks (mean change 18.1 m, 95% confidence interval 11.6 m to 24.6 m). Conclusion: A moderate to high intensity aerobic and strength exercise training programme does not slow cognitive impairment in people with mild to moderate dementia. The exercise training programme improved physical fitness, but there were no noticeable improvements in other clinical outcomes.
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Association of Low Vitamin D with Complications of HIV and AIDS: A literature ReviewWith the advent of combination antiretroviral therapy (cART), the survival of HIV patients has improved dramatically, but the complications of the disease and treatment have become an important issue in the management of HIV patients. Vitamin-D deficiency is common in HIV patients. Low vitamin-D is associated with different comorbidities in the HIV uninfected general population. In this review, we first briefly describe vitamin D synthesis and mechanism of action and we focus on the epidemiological and clinical data dealing with the relationship between vitamin D deficiency in HIV infection with several comorbidities which has been found to be increasingly common in patients living with HIV infection. We searched the PubMed database using the keywords "HIV," "vitamin D" and other common disorders or conditions that are relatively common in HIV infection. The other conditions included in the search were osteoporosis and fracture, cardiovascular disease, diabetes and insulin resistance, active tuberculosis, hepatitis-C co-infection, and HIV disease progression. Articles presenting original data as well as systematic reviews and met analysis related to HIV population were included in our analysis. Vitamin-D deficiency seems to be associated with several adverse outcomes in HIV patients but a definite cause and effect relationship with vitamin-D is yet to be confirmed in most of the cases. However, the literature supporting the efficacy of vitamin-D supplementation is lacking.
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QI 117 Improving Physical Health Care Provided by Coventry 11-17 (Psychosis Pathway) TeamAim: By 9 July 2022 for patients open to medical staff only in the Coventry Recovery Team (N=96): 1. 30% will have been offered an appointment to complete the lifestyle screening tool. 2. 20% will have had a physical health and lifestyle screening tool completed. The trust requires that all patients open to the service with psychotic disorders have an annual physical health screening assessment. Prior to this project there was a nurse and health care led process in place which was unable to meet these requirements. Baseline data showed that of those patients only open to the medical team 13.5% had been offered a physical health screen and only 12.5% had a completed assessment over the past 3 years. Tools Used: PDSA - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf; Driver Diagram - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf; SPC - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-statistical-process-control.pdf; Process Mapping - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-mapping-the-process.pdf; Project Impact: Completed physical health assessments increased from baseline by 20% up to 32.5% at week 16. Cycle 2: aimed at non-attendance. Providing generic information improved this by 3.6% but a personalised letter to non-attenders at a 1st appointment (n=3) resulted in them all attending a 2nd appointment.
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QI 102 Implementing a Telephone Triage System in Integrated Sexual Health Service (ISHS)Aim: To reduce in-clinic waiting times for patients attending the open access clinic by 50% by 31st January 2020. Prior to the Covid-19 pandemic a face-to-face triage system was in place. Being a walk-in service, patients were required to queue before entering the department. If clinic capacity was reached, they would have to be turned away. There were frequently long in-clinic wait times (on an average 73 minutes) before first contact with the clinician could occur. In response to the pandemic, a telephone triage system was implemented. The aim of this was to reduce the in-clinic waiting time and provide a safe and effective system during the pandemic. Tools Used: Driver Diagram - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf; PDSA Cycle - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf. Project Impact: 70% of patients said that they had to wait for less time than the previous attendance. •83% of patients felt comfortable sharing information over the telephone. •100% of patients were satisfied with the outcome of the triage. •87% of patients were satisfied with the service offered. •Overall staff preferred the new telephone triage system. The waiting room is quieter and there is less pressure on the reception team.
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The NHS and Private HealthcareThe National Health Service was founded in 1948 to provide free healthcare to all citizens, with the anticipation that this would improve the general health of the population, and thus ultimately reduce the cost of ill health on the economy. Unfortunately, healthcare costs have risen continually since the inception of the NHS due to an ageing population, increasing public expectations of the health service and advances in medical technology resulting in increasingly costly interventions. Despite continually rising costs and changes to the structure and management of the NHS, it remains a successful and effective system of healthcare.
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British Thoracic Society quality standards for home oxygen use in adultsIntroduction: The purpose of the quality standards document is to provide healthcare professionals, commissioners, service providers and patients with a guide to standards of care that should be met for home oxygen provision in the UK, together with measurable markers of good practice. Quality statements are based on the British Thoracic Society (BTS) Guideline for Home Oxygen Use in Adults. Methods: Development of BTS Quality Standards follows the BTS process of quality standard production based on the National Institute for Health and Care Excellence process manual for the development of quality standards. Results: 10 quality statements have been developed, each describing a key marker of high-quality, cost-effective care for home oxygen use, and each statement is supported by quality measures that aim to improve the structure, process and outcomes of healthcare. Discussion: BTS Quality Standards for home oxygen use in adults form a key part of the range of supporting materials that the society produces to assist in the dissemination and implementation of a guideline’s recommendations.
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A prospective mixed-methods pilot study of a novel group structured education programme for adults with cystic fibrosis diabetesBackground: Cystic fibrosis diabetes (CFD) is associated with increased morbidity and mortality in adults with cystic fibrosis (CF). In addition, poor glycaemic control can result in microvascular complications. Group educational programmes for people with type 1 and 2 diabetes have been shown to improve diabetes outcomes. The national guidelines recommend that people with CFD should receive education regarding diabetes; however, specific CFD group education programmes have not been evaluated. Aims: This study aimed to test whether this novel diabetes contents and intervention for CFD based on the Beta Cell Education Resources for Training in Insulin and Eating (BERTIE) type 1 diabetes education programme was beneficial for adults with CFD. The adapted course, Improved Diabetes Education in Adults with Cystic Fibrosis (IDEA-CF ), incorporated CFD-specific topics and was delivered virtually via videoconference group sessions to facilitate peer learning and support without the risk of cross-infection. A pilot study was conducted utilising this novel IDEA-CF virtual structured program to ensure that the intervention met the patients’ educational needs. Methods: This randomised controlled multimethods pilot study recruited adults with CFD taking insulin therapy and cared for by a large regional CF centre. After providing written informed consent, the participants completed all the study forms and questionnaires before randomisation. Randomisation was performed using a computerised randomisation system that allocated adults with CFD into the intervention group (IDEA-CF) or routine care group for the 12-week study period. Participants who were randomised into the routine group continued to receive one-on-one education as before. Using the CF quality-of-life (QoL) questionnaire (revised Cystic Fibrosis Questionnaire [CFQ-R]), outcomes were measured at baseline and 12-week visits in both groups. The participants in the intervention group were asked to take part in a semistructured qualitative interview after the completion of the intervention, which was performed by a CF psychologist. Results: A total of 20 participants were recruited, with 18 completing the intervention and study follow-up visits. In the CFQ-R domains, physical functioning, emotional functioning, eating, role functioning and respiratory symptoms were significantly improved in the intervention group compared with the routine care group. The IDEA-CF Knowledge Assessing Questionnaire (IDEA-CF KAQ) scores in the intervention group improved compared with the IDEA-CF KAQ scores in the control group, suggesting that education improves knowledge and understanding. The IDEA-CF structured virtual group education group was well received, with participants valuing the educational content and the ability to interact with each other and to learn from their peers’ experiences constructively. Conclusions: Our study demonstrated that the IDEA-CF education programme improved health-related QoL and diabetes knowledge, as evidenced by the results of the IDEA-CF KAQ. The participants valued the educational contents of the programme and reported a positive experience interacting with their peers.
