Publications

This study aimed to evaluate the prevalence of sexually transmitted infections (STIs) and associated risk factors in HIV-infected pregnant women followed for prenatal care in Salvador, Bahia. This was a cross-sectional study of 63 women seeking prenatal care at a reference center. Participants were interviewed regarding socio-epidemiological and clinical history, and were tested for HBsAg, anti-HCV, anti HTLV I/II, VDRL, Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma hominis, Ureaplasma urealyticum, CD4 count, and HIV plasma viral load. The main outcome variable was the presence of any STI. The mean age of patients was 28.2 years (16-40 years). 23 (36.5%) were diagnosed with at least one STI. The frequency of diagnoses was: HBV, 3.2%; HCV, 8.1%; HTLV I/II, 3.4%; syphilis, 9.5%; Chlamydia trachomatis, 11.1%; HPV, 15.0%; Mycoplasma hominis, 2.1%, and Ureaplasma urealyticum, 2.1%. No case of Neisseria gonorrhoeae was identified. No association was found between socio-epidemiological variables and the presence of an STI. CD4 T lymphocyte < 500 cells/μL (p=0.047) and plasma viral load >1,000 copies (p = 0.027) were associated with the presence of STI. STIs are frequent in pregnant women infected with HIV, and all HIV-infected pregnant women should be screened to decrease transmission of these pathogens and to protect their own health.

Pneumocystis jirovecii pneumonia (PCP) is an important opportunistic infection in patients infected with HIV, but its burden is incompletely characterized in those areas of sub-Saharan Africa where HIV is prevalent. We explored the prevalence of both PCP in HIV-infected adults admitted with pneumonia to a tertiary-care hospital in Uganda and of putative P. jirovecii drug resistance by mutations in fungal dihydropteroate synthase (dhps) and dihydrofolate reductase (dhfr). In 129 consecutive patients with sputum smears negative for mycobacteria, 5 (3.9%) were diagnosed with PCP by microscopic examination of Giemsa-stained bronchoalveolar lavage fluid. Concordance was 100% between Giemsa stain and PCR (dhps and dhfr). PCP was more prevalent in patients newly-diagnosed with HIV (11.4%) than in patients with known HIV (1.1%; p = 0.007). Mortality at 2 months after discharge was 29% overall: 28% among PCP-negative patients, and 60% (3 of 5) among PCP-positive patients. In these 5 fungal isolates and an additional 8 from consecutive cases of PCP, all strains harbored mutant dhps haplotypes; all 13 isolates harbored the P57S mutation in dhps, and 3 (23%) also harbored the T55A mutation. No non-synonymous dhfr mutations were detected. PCP is an important cause of pneumonia in patients newly-diagnosed with HIV in Uganda, is associated with high mortality, and putative molecular evidence of drug resistance is prevalent. Given the reliability of field diagnosis in our cohort, future studies in sub-Saharan Africa can investigate the clinical impact of these genotypes.

OBJECTIVE

To determine the impact of prenatal counseling regarding psychosocial risk factors on maternal behavior.

STUDY DESIGN

We analyzed data from 198,323 women participating in the Pregnancy Risk Assessment Monitoring System (PRAMS). The χ(2) and logistic regression analyses assessed the relationship between psychosocial risk, prenatal counseling and maternal behavior.

RESULTS

The odds of receiving risk-appropriate prenatal counseling were significantly greater for participants who used alcohol (odds ratio, 1.13; 95% confidence interval, 1.08-1.17) and tobacco (odds ratio, 2.02; 95% confidence interval, 1.91-2.13). After receiving counseling, women quit using alcohol (72.9% vs 27.1%; P < .01) and tobacco (79.9% vs 20.1%; P < .01) at a significantly greater rate and women with unintended pregnancies were more likely to use postpartum contraception (83.6% vs 16.4%; P < .01) than women who were not counseled. However, no significant differences were found in the rates of intimate partner violence during pregnancy (56.1% vs 43.9%; P = .09) between women who did and did not receive counseling.

CONCLUSION

Counseling regarding psychosocial risk factors during pregnancy may positively impact maternal behavior.

Palliative care in the U.S. has evolved from a system primarily reliant on community-based hospices to a combined model that includes inpatient services at most large hospitals. However, these two dominant approaches leave most patients needing palliative care-those at home (including nursing homes) but not yet ready for hospice-unable to access the positive impacts of the palliative care approach. We propose a community-based palliative care (CPC) model that spans the array of inpatient and outpatient settings in which palliative care is provided and links seamlessly to inpatient care; likewise, it would span the full trajectory of advanced illness rather than focusing on the period just before death. Examples of CPC programs are developing organically across the U.S. As our understanding of CPC expands, standardization is needed to ensure replicability, consistency, and the ability to relate intervention models to outcomes. A growing body of literature examining outpatient palliative care supports the role of CPC in improving outcomes, including reduction in symptom burden, improved quality of life, increased survival, better satisfaction with care, and reduced health care resource utilization. Furthermore the examination of how to operationalize CPC is needed before widespread implementation can be realized. This article describes the key characteristics of CPC, highlighting its role in longitudinal care across patient transitions. Distinguishing features include consistent care across the disease trajectory independent of diagnosis and prognosis; inclusion of inpatient, outpatient, long-term care, and at-home care delivery; collaboration with other medical disciplines, nursing, and allied health; and full integration into the health care system (rather than parallel delivery).