Included in the 2012 International Antiviral Society-USA panel recommendations for human immunodeficiency virus (HIV) patient care is that all adult patients, regardless of CD4 cell count, should be offered antiretroviral therapy (ART), according to an article. Other new recommendations include changes in therapeutic options and modifications in the timing and choice of ART for patients with an opportunistic illness such as tuberculosis.
Melanie A. Thompson, M.D., of the AIDS Research Consortium of Atlanta, presented the findings of the article at a JAMA media briefing at the International AIDS Conference.
‘Since the first antiretroviral drug was approved 25 years ago, improvements in the potency, tolerability, simplicity, and availability of ART have resulted in dramatically reduced numbers of opportunistic diseases and deaths where ART is accessible,’ according to background information in the article. ‘New trial data and drug regimens that have become available in the last 2 years warrant an update to guidelines for ART in HIV-infected adults in resource-rich settings.’
Dr. Thompson and colleagues with the International Antiviral Society-USA panel conducted a review of the medical literature to identify relevant evidence published since the last report (2010), as well as data that had been published or presented in abstract form at scientific conferences in the past 2 years. The revised guidelines reflect new data regarding recommendations of when to initiate ART, new options for initial and subsequent therapy, ART management in the setting of special conditions, new approaches to monitoring treatment success and quality, and managing antiretroviral failure.
Among the primary recommendations of the panel are that treatment is recommended for all adults with HIV infection. The researchers found that there is no CD4 cell count threshold at which starting therapy is contraindicated, but the strength of the recommendation and the quality of the evidence supporting initiation of therapy increase as the CD4 cell count decreases and when certain concurrent conditions are present. Patients should be monitored for their CD4 cell count, and also HIV-1 RNA levels, ART adherence, HIV drug resistance, and quality-of-care indicators.
Initial regimens that are recommended include 2 nucleoside reverse transcriptase inhibitors (tenofovir/emtricitabine or abacavir/lamivudine) plus a non-nucleoside reverse transcriptase inhibitor (efavirenz), a ritonavir-boosted protease inhibitor (atazanavir or darunavir), or an integrase strand transfer inhibitor (raltegravir). ‘The aim of therapy continues to be maximal, lifelong, and continuous suppression of HIV replication to prevent emergence of resistance, facilitate optimal immune recovery, and improve health’ the authors write. Alternatives in each class are recommended for patients with or at risk of certain concurrent conditions, including cardiovascular disease, reduced kidney function, or tuberculosis.
The primary reasons for switching regimens include virologic, immunologic, or clinical failure and drug toxicity or intolerance. Switching regimens in virologically suppressed patients to reduce toxicity, improve adherence and tolerability, and avoid drug interactions can be done by switching 1 or more agents in the regimen. ‘Confirmed treatment failure should be addressed promptly and multiple factors considered,’ the researchers write.
‘Although it is crucial to intensify efforts to find a cure for persons who are already infected and an effective vaccine for those who are not, many of the tools needed to control the HIV/AIDS pandemic are already at hand. Critical components of the tool kit to eradicate AIDS include expanded HIV testing, increased focus on engagement in HIV care, early and persistent access to ART, and attention to improving ART adherence. These must occur in the context of strategies to address social determinants of health, including the elimination of stigma and discrimination,’ the authors conclude. EurekAlert

A Rhode Island Hospital radiation oncologist says in a new editorial that research exploring the impact of radiotherapy in older women with low risk of breast cancer recurrence has little effect on actual clinical decisions. The editorial written by David E. Wazer, MD, chief of the department of radiation oncology, is published in the currently being published.
Breast-conserving therapy (BCT) has shown to have comparable outcomes to mastectomy, allowing women to preserve their breast without compromising their chance of being cured of cancer. BCT also has been associated with improved quality of life, as compared to mastectomy. Radiation therapy is an integral part of BCT, and its benefit is clearly dependent on the baseline risk of ipsilateral breast tumor recurrence (IBTR) after surgical excision alone, and is small in patients at low risk of recurrence. Multiple trials have shown that the IBTR risk decreases with age, and has prompted analysis of the benefit of radiotherapy for older patients with breast cancer.
‘If an older patient has been treated for breast cancer, and has a low risk of recurrence, there may be no clinical reason to subject them to radiation therapy,’ Wazer said. ‘It

Psychological factors can have as much-or more-impact on pediatric chest pain as physical ones, a University of Georgia study found recently. UGA psychologists discovered pediatric patients diagnosed with non-cardiac chest pain have higher levels of anxiety and depression than patients diagnosed with innocent heart murmurs-the noise of normal turbulent blood flow in a structurally normal heart.
The UGA research was done in collaboration with Children’s Healthcare of Atlanta and Emory University.
‘The fact that these psychological symptoms are higher in non-cardiac chest pain patients suggests the psychological symptoms may be playing a role in the presentation of chest pain,’ said Jennifer Lee, a doctoral candidate in the UGA Franklin College of Arts and Sciences and the study’s lead author.
The results of the study show a statistically significant increase in anxiety and depression among patients who are later diagnosed with non-cardiac chest pain when compared to patients diagnosed with innocent heart murmurs. Lee said it is not clear if the anxiety is a cause of the pain or if pain caused the anxiety in the sample group.
‘The higher levels weren’t so high as to cause a clinical diagnosis on their own, but when you contrast the two groups, there were statistically significant differences,’ said study co-author Ronald Blount, a psychology professor in the Franklin College.
The study included 129 patients ages 8 to 18. The group completed surveys prior to diagnosis. All patients were essentially in the same situation-sitting in a cardiology office awaiting their unknown medical diagnosis.
‘We are highlighting that psychology has a part in these symptoms,’ Blount said, ‘and screening for psychological, as well as medical factors, is one implication we foresee coming from this investigation.’
Chest pain can indicate serious medical conditions that require a doctor’s evaluation. In adults, pain in the chest is often linked to a cardiac problem. In children, however, less than 2 percent of patients receive a cardiac diagnosis for their pain.
The Sibley Heart Center at Children’s Healthcare of Atlanta is one of the largest pediatric heart centres in the world, seeing an average of 2,500 new patients with acute chest pain each year.
‘We know up front that 99 percent of these patients will not have a heart complication at all. The trick is, it is not zero, and I cannot miss the one patient with heart disease because the consequences could be catastrophic,’ said Dr. Robert Campbell, chief of the Sibley Heart Center and division director of the department of pediatrics at the Emory University School of Medicine.
The study also observed that non-cardiac chest pain patients have a higher level of functional disability-or the inability to participate in everyday activities like running across a football field or making it through a day without a nap. They also spent less time at school and were less involved in extra-curricular activities.
‘These kids also report greater levels of physical symptoms with unclear causes, like joint pain, stomach aches, head aches,’ Lee said. ‘These symptoms are believed to be psychological manifestations of stress. Sometimes your brain doesn’t tell you that you are stressed out, but your body does, so you will experience symptoms like these.’
Pediatric patients with non-cardiac chest pain also reported higher levels of anxiety sensitivity, a fear of experiencing physical symptoms and additionally fearing that those symptoms are related to a catastrophic health issue.
‘Psychological functioning is heavily related to pain,’ Blount said. ‘Pain is a sensory experience, but your attention to one thing or another and your emotions can impact your experience of pain. And how debilitating the pain is for you can be determined by psychological and social factors. That is what we were interested in looking at.’
Previous studies have shown reducing emotional symptoms can lead to better coping ability with pain, Lee said. ‘A goal with these patients would be to create a clearer, more comprehensive picture of what is going on and determine a better way to help these kids and adolescents.’
Campbell said the UGA research helps him serve the majority of his patients who leave his office with a clean bill of health but unexplained chest pain.
‘Most importantly what we’ve learned is that after a physical evaluation of the patient, we take the time to sit down with the family and find out what they are most worried about so we can address their psychological issues,’ Campbell said. ‘We’ve learned to pay attention and to be confident and reassuring. I need to make it clear to my patients and their parents that I’m not saying you are not having pain, but that the pain is not caused by your heart.’ University of Georgia