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Miami-Dade County (MDC) represents a major port of entry for people seeking asylum in the United States, and few studies have systematically evaluated the demographic characteristics of this vulnerable population. Moreover, while the burden of post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) are thought to be higher in this population, the prevalence of these psychiatric conditions in our community is unknown. An analysis of demographics and psychiatric co-morbidities of the Human Rights Clinic (HRC) of Miami's 93 clients between 2010 and 2015 was conducted. The HRC cohort had the following characteristics: median age of 30 years, 52% female, 46% male, 2% transgender or intersex, and 88% originating from Latin America and the Caribbean. The prevalence of PTSD was 67% and MDD was 53% in the HRC population. We conclude that the mental health burden in asylum-seekers in MDC is alarmingly high and that healthcare providers should remain keenly attentive to the unique needs of this population.

Introduction: The THRIVE Clinic provides medical/psychiatric care for human trafficking survivors in Miami. Designed to address the comprehensive healthcare needs of this unique population, the cli...

Introduction While research suggests that asylum-seekers often present with a high level of medical and psychological needs, there is a dearth of research exploring sleep quality in this population, and, accordingly, the role that the sleep medicine community may be able to play in alleviating the suffering of this population. Therefore, this study aims to assess the prevalence of sleep disruption amongst asylum-seekers presenting to a South Florida clinic and to categorize these disruptions according to severity and type. Methods This is a cross-sectional study utilizing medical affidavits for asylum seekers in South Florida from 2018-2020 (n=54). Affidavits were reviewed for narrative descriptions of sleep quality and information from validated screeners regarding sleep; demographic information was also collected. Affidavits were excluded if they did not include itemized answers to screening questions. Results Out of 54 asylum-seekers (31% male, median age=34.5 years), 72.2% reported sleep disturbance. 38.9% reported nightmares, 66.7% reported insomnia of any type, and 29.6% reported severe insomnia. Asylum-seekers that screened positive for post-traumatic stress disorder (PTSD) were more likely to report ongoing sleep disturbance than asylum-seekers that screened negative for PTSD (p=.004). Sleep disturbance prevalence did not vary significantly by gender identity or country of origin. Conclusion This study reveals a high prevalence of sleep disruption amongst asylum-seekers in South Florida. The asylum-seekers in our study were more likely to experience insomnia than nightmares, but many experienced both; sleep disturbance was significantly associated with screening positive for PTSD. Our findings suggest that physicians working with asylum-seekers should ask about sleep quality and offer appropriate care. Directions for further research include investigating how poor sleep quality impacts the health and wellbeing of asylum-seekers. Support (if any) None

ObjectiveAsylum seekers experience a high burden of physical and psychological trauma, yet there is a scarcity of literature regarding the epidemiology and sequelae of head injury (HI) in asylum seekers. We examined HI prevalence and association with neuropsychiatric comorbidities in asylum seekers.MethodsA retrospective cross-sectional study was performed through review of 139 medical affidavits from an affidavit database. Affidavits written from 2010 to 2018 were included. Demographic and case-related data were collected and classified based on the presence of HI. For neuropsychiatric sequelae, the primary study outcome was headache and the secondary outcomes were depression, posttraumatic stress disorder, and anxiety. Multivariable logistic regression was performed to examine the association between HI and neuropsychiatric sequelae, adjusted for demographic and clinical characteristics.ResultsA total of 139 medical affidavits of asylum seekers were included. The mean age was 27.4 ± 12.1 years, 56.8% were female, and 38.8% were ConclusionsWe observed a high prevalence of HI in asylum seekers. Comprehensive screening for HI and neuropsychiatric comorbidities is encouraged when evaluating asylum seekers.

AIDS-related mortality remains a leading cause of preventable death among African-Americans. We sought to determine if community health workers could improve clinical outcomes among vulnerable African-Americans living with HIV in Miami, Florida. We recruited 91 medically indigent persons with HIV viral loads ≥1,000 and/or a CD4 cell count ≤350. Patients were randomized to a community health worker (CHW) intervention or control group. Viral load and CD4 cell count data were abstracted from electronic medical records. At 12 months, the mean VL in the intervention group was log 0.9 copies/μL lower than the control group. The CD4 counts were not significantly different among the groups. Compared to the control group, patients randomized to CHWs experienced statistically significant improvements in HIV viral load. Larger multi-site studies of longer duration are needed to determine whether CHWs should be incorporated into standard treatment models for vulnerable populations living with HIV.

On average, 4 clinical questions arise per patient encounter1 and about half the time, information needs are left unresolved.2 There is significant interest in capturing, sharing, and using knowledge within the daily work of health professionals in order to improve health outcomes. The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act offers up to $27 billion over 10 years to providers demonstrating “meaningful use” of electronic health records (EHRs).3 “Meaningful use” implies more than just recording information; use of the EHR should improve patient care.

We examined alcohol use patterns and adherence to antiretroviral therapy (ART) among 45 people living with HIV (PLWH) in Miami, Florida. Documented provider knowledge of alcohol use was also assessed. Among our sample, 20 % reported "weekending," a phenomenon we describe as skipping ART due to planned alcohol use and drinking more on the weekend. While 100 % of our sample reported alcohol use, 73 % of providers' notes reported abstinence. Until larger studies assess the generalizability of these findings among other PLWH, providers should consider probing patients about when they drink, how much they drink, and if they take ART when drinking.

A 49-year-old African American woman (S.A.) has been receiving HIV specialty and primary care in an urban hospital-based adult HIVoutpatient clinic since 2001. She has also been followed by colorectal surgery and HIV gynecology clinics. Her social history includes a 45-pack/year tobacco habit and crack cocaine use since 1982, but she has denied alcohol use. S.A. presented to the emergency room in March 1997 with shortness of breath, and the hospital admitted her with presumptive Pneumocystis jiroveci pneumonia. She tested positive for HIVinfection, and her CD41 T cell count was 7 cells/mm 3 . Her surgical history was significant for a Bartholin cyst incision and drainage 15 years prior. Her discharge medications included sulfamethoxazole/trimethoprim and azithromycin with a follow-up appointment in the adult HIV clinic scheduled for 2 weeks later; she was not started or discharged on antiretroviral therapy (ART). She failed to follow up in the adult HIVoutpatient clinic but was subsequently admitted in 1998 for orbital cellulitis and cytomegalovirus retinitis with blindness, and in 1999 for seizures, at which time she was diagnosed with cryptococcol meningitis. The last admission note indicated that the patient had not taken her ART in 5 months; however, the names of the medications that she was previously on were not specified. S.A. was lost to follow-up until July 2001 when she was brought to the emergency room from

Objectives Highly active antiretroviral therapy (HAART) has transformed HIV infection into a manageable chronic illness, yet AIDS mortality among ethnic minorities persists in the USA. HAART nonadherence is associated with increased HIV viral load, low CD4 cell count and racial disparities in HIV outcomes. While there is no universal consensus on how to improve medical adherence in HIV-positive populations, the community health worker (CHW) model is emerging as an effective strategy to overcome barriers to HAART adherence. Although utilized in international settings, there is little evidence regarding the effects of CHWs on HIV outcomes in the USA. Methods We performed a comprehensive search from May 2010 to November 2010 to identify studies carried out in the USA that utilized CHWs to improve HAART adherence and measured HIV viral loads and CD4 cell counts to assess intervention effects. Sixteen studies met the inclusion criteria and were reviewed for this article. All studies reported clinical HIV outcomes. Results Interventions that lasted at least 24 weeks, provided frequent contact with participants, and focused on medication management were associated with improved HAART adherence, as indicated by reduced HIV viral load and increased CD4 cell count. Conclusions Compared with current standards of care, CHW programmes may offer a practical and cost-effective alternative to improve HAART adherence, which may lead to reduced HIV viral load and increased CD4 cell counts among HIV-positive populations in the USA.

OBJECTIVES: To validate the use of a script concordance test (SCT), a tool to assess clinical reasoning in contexts of uncertainty, which are common in clinical geriatrics practice, on geriatric urinary incontinence (UI) to discriminate levels of expertise in this content area. DESIGN: A reference panel (15 geriatricians) and 12 respondents (10 senior geriatrics fellows and 2 interns) completed an online 100-item SCT test covering major topics in UI. The test was then optimized by discarding items with negative item–total correlation; the remaining 70 questions covered all major topics in UI. The test was then administered to a second group of participants with different levels of experience, mostly from the University of Miami: eight geriatricians, nine junior geriatrics fellows, 53 internal medicine residents, and 26 medical students. Investigators assessed test reliability and construct validity (to discriminate between levels of expertise). SETTING: Tertiary academic medical center and affiliated medical school. PARTICIPANTS: Medical students, internal medicine residents, geriatric medicine fellows, and practicing geriatricians. MEASUREMENTS: Seventy-item SCT. RESULTS: The Cronbach alpha for the 70-item test was 0.72. Mean scores were 75.3 � 7.9 for geriatricians (n 5 23), 69.0 � 9.3 for senior geriatrics fellows (n 5 10), 66.4 � 6.8 for junior geriatrics fellows n 5 (9), 66.1 � 5.7 for residents (n 5 53), and 65.6 � 8.5 for students (n 5 26). Using analysis of variance, significant differences were found between the mean scores of the geriatricians and all other participants except senior fellows. CONCLUSION: The geriatric UI SCT demonstrated moderate reliability and evidence of construct validity, discriminating between experienced and nonexperienced physicians. J Am Geriatr Soc 58:2178–2184, 2010.

The clinical presentation of colitis associated with Clostridium difficile infection in immunosuppressed patients with acquired immunodeficiency syndrome (AIDS) has not been completely characterized. Previous reports suggest that these patients present with low blood leukocyte counts, consistent with the impaired myelopoiesis that can occur with human immunodeficiency virus (HIV) infection. In contrast, we describe the cases of two patients with colitis associated with C difficile infection who developed intense leukemoid reactions despite being in advanced stages of AIDS. To the best of our knowledge, these are the first described cases of leukemoid reaction associated with C difficile or other bacterial infection in AIDS patients. We review the literature on C difficile colitis in patients infected with HIV and suggest that severe C difficile infection should be considered in such patients presenting with leukemoid reaction and diarrhea.

Background The purpose of the study was to examine the relationship between age and plasma viral load in HIV-1-infected individuals. Design The experimental method was to recruit older (> 50 years of age) and younger (18-39 years of age) HIV-1-infected individuals. The plasma viral load was measured using the Roche Molecular Systems UltraSensitive Roche HIV-1 Monitor test reflexively with the standard Amplicor HIV Monitor test to quantify viral load in the range of 50-750,000 copies of HIV-1 RNA/ml plasma. Subjects A total of 135 HIV-1-seropositive individuals (at Centers for Disease Control and Prevention early symptomatic stage B or late symptomatic stage/AIDS C) were enrolled as part of a larger cohort also consisting of HIV-1-seronegative individuals. Results A generalized linear models statistical analysis was conducted in order to evaluate age category as a predictor of plasma viral load. The result was a significant effect of age category, with older age associated with a lower plasma viral load. The association held controlling for antiretroviral therapy usage, disease stage, antiretroviral medication adherence, HIV-1 serostatus duration, alcohol and substance use, recent sexually transmitted disease, and sociodemographics (except income). Conclusion Older age was associated with lower levels of HIV-1 replication in this sample, independent of antiretroviral therapy usage, regimen adherence, and disease stage. It is suggested that the effect may be caused by changes in viral evolution or immunological monitoring specific to older individuals with HIV-1 infection.

Older individuals (>50 years of age) now comprise over 11% of patients with AIDS in the United States. This percentage is expected to continue to grow, due both to the improved longevity of patients prescribed highly active antiretroviral therapy (HAART) and to new infections among older individuals. This review focuses on the neuropsychiatric and neurological conditions that are most likely to be affected by advancing age-HIV-1-associated cognitive-motor disorder, peripheral neuropathy, progressive multifocal leukoencephalopathy, primary CNS lymphoma, and risk for cerebrovascular accident. Age associations with incidence of these disorders and with treatment foci are specified. Implications for future changes in management are discussed.

Context and setting Because there is a lack of standardised methodology to teach invasive bedside procedures, the incidence of associated complications remains unacceptably high and variations in teaching may be a contributing factor. Successful interventions are needed to change these poor outcomes and improve patient safety. Therefore, the University of Miami-Jackson Memorial Hospital Center for Patient Safety (CPS) launched an innovative educational initiative. Specifically designed to fill the training gap, the programme provides a standardised curriculum for procedural instruction. Why the idea was necessary At academic medical centres throughout the USA, residents perform the majority of invasive bedside procedures. By contrast with the apparent flaws in the outdated and frequently unsafe ‘see one, do one, teach one’ model of training, standardised procedural training targets hands-on learning and direct observation as the keystones for building confidence and competence. What was done To capitalise on this educational opportunity, a uniform teaching method was created incorporating the six Accreditation Council for Graduate Medical Education core competencies: patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism, and systems-based practice. We developed a simulation-based curriculum for those procedures recently listed by the American Board of Internal Medicine as necessitating technical competence (central venous catheter insertion, lumbar puncture, paracentesis, thoracentesis), tailored for residents who will be asked to deliver these critical aspects of patient care. Our initiative combines the established, efficacious use of simulators, practice with ultrasound and the utility of checklists in ensuring patient-safe practices. To date, we have trained anaesthesiology, emergency medicine, internal medicine, neurology and surgery residents and medical students. The four pillars of the procedural training include

Background. Human immunodeficiency virus (HIV)-associated tuberculosis is difficult to treat, given the propensity for drug interactions between the rifamycins and the antiretroviral drugs. We examined the pharmacokinetics of rifabutin before and after the addition of lopinavir-ritonavir. Methods. We analyzed 10 patients with HIV infection and active tuberculosis in a state tuberculosis hospital. Plasma was collected for measurement of rifabutin, the microbiologically active 25-desacetyl-rifabutin, and lopinavir by validated high-performance liquid chromatography assays. Samples were collected 2-4 weeks after starting rifabutin at 300 mg thrice weekly without lopinavir-ritonavir, 2 weeks after the addition of lopinavir-ritonavir at 400 and 100 mg, respectively, twice daily to rifabutin at 150 mg thrice weekly, and (if rifabutin plasma concentrations were below the normal range) 2 weeks after an increase in rifabutin to 300 mg thrice weekly with lopinavir-ritonavir. Noncompartmental and population pharmacokinetic analyses (2-compartment open model) were performed. Results. Rifabutin at 300 mg without lopinavir-ritonavir produced a low maximum plasma concentration (C max ) in 5 of 10 patients. After the addition of lopinavir-ritonavir to rifabutin at 150 mg, 9 of 10 had low C max values. Eight patients had dose increases to 300 mg of rifabutin with lopinavir-ritonavir. Most free rifabutin (unbound to plasma protein) C max values were below the tuberculosis minimal inhibitory concentration. For most patients, values for the area under the plasma concentration-time curve were as low or lower than those associated with treatment failure or relapse and with acquired rifamycin resistance in Tuberculosis Trials Consortium/US Public Health Service Study 23. One of the 10 patients experienced relapse with acquired rifamycin resistance. Conclusion. The recommended rifabutin doses for use with lopinavir-ritonavir may be inadequate in many patients. Monitoring of plasma concentrations is recommended.

Pneomocystis jiroveci pneumonia (PCP) is still the leading cause of death in patients with acquired immunodeficiency syndrome (AIDS) who are not receiving highly active antiretroviral therapy (HAAR...

Adult-onset (type 2) diabetes mellitus (DM) has become an increasing concern in the field of HIV/AIDS since the introduction of highly active antiretroviral therapy (HAART), now referred to as combination antiretroviral therapy (CART), in 1996. The increased incidence of DM has occurred as a long-term toxic side effect of the use of two classes of antiretroviral (ARV) agents – the protease inhibitors (PIs) and the nucleoside reverse transcriptase inhibitors (nRTIs), predominantly the former. However, it is also thought that the prevalence of metabolic syndrome (characterized by central obesity, dyslipidemia, hypertension, and insulin resistance) associated with DM outside of HIV-1 infection increases in prevalence in the setting of HIV-1 infection. We will examine in this chapter how the risks for DM in the general population interact with those in HIV-1-infected individuals to produce a higher risk for DM and its associated complications of coronary artery disease (CAD), myocardial infarction (MI), and cerebrovascular accident (CVA). We will then examine how neuropsychiatric disorders and treatments common in HIV-1 infection may play a role in the development and treatment of type 2 DM. Finally, we will examine the specific recommendations for neuropsychiatric treatment in the setting of HIV-1 infection complicated by type 2 DM.

In young adults, a major neurologic complication of HIV-1 infection is cognitive motor impairment. Epidemiologic findings suggest that increasing age is a significant risk factor for HIV-1-associated dementia as the AIDS-defining illness. Findings from the few studies that have directly measured cognition in younger and older HIV-1-infected adults, however, have been mixed, in part, because of small sample sizes and other methodologic differences between studies. The authors present preliminary findings on cognitive functioning in symptomatic HIV-1-infected younger (aged 20-39 years) and older (aged 50 years or older) adults. Independent of age, HIV-1 infection was accompanied by learning and memory retrieval deficits, which were significantly associated with high plasma viral loads in the young adults. Relative to the younger and older HIV-1-negative (HIV-1-) groups, only the younger HIV-1-positive (HIV-1+) group had significantly longer reaction times (RTs). Within the older HIV-1+ group, however, longer simple and choice RTs were significantly correlated with higher viral loads and lower CD4 cell counts. Although HIV-1 infection affects cognition independent of age, longitudinal studies involving large numbers of older individuals are needed to determine whether there are age differences in the prevalence, nature, and severity of HIV-1-associated cognitive dysfunction.

Objective evaluations of residents' clinical skills reveal serious deficits.To develop, implement, and evaluate outcomes from a review course in cardiology bedside skills for internal medicine residents.We used a 1-group pretest-posttest design with historical comparisons. The study was conducted at the University of Miami School of Medicine as part of the internal medicine residency program from July 1999 to June 2000. A total of 67 2nd- and 3rd-year medicine residents received an educational intervention involving deliberate practice using simulation technology. A total of 155 4th-year medical students in one intervention and one comparison group (n = 53) served as historical comparisons. Outcome measures were a reliable computer-delivered pretest and posttest that evaluate cardiology bedside skills.Residents who received the review course and medical students who received a comparable educational intervention showed large and statistically significant pretest-to-posttest improvement in bedside skills. These 2 groups are also significantly and substantially different at posttest from a comparison group of 4th-year medical students that did not receive a specific educational intervention.Educational interventions using simulation technology that engage learners in deliberate practice of clinical skills produce large improvements in a relatively short time, with little faculty involvement.

Background: HIV infection has been associated with endothelial dysfunction. Endothelial microparticles (EMP) are informative markers of endothelial cell status and can exert transcellular effects in leukocytes. No previous studies have assessed EMP and their interactions with leukocytes in HIV-infected patients. Methods: We studied 29 patients (mean age = 42.1±7 years) with HIV infection on HAART who demonstrated an optimal viral and immunological response (CD4+ cell count>200 /mm3 and < 50 viral copies/ml by PCR analysis). Patients with diabetes, smoking, thrombotic, cardiovascular or malignant disease were excluded. We used age- and gender-matched healthy controls. Using flow cytometry, we measured free EMP identified by: 1. Expression of CD31 and lack of expression of CD42b (EMP31); 2. E-selectin expression (EMP62E); 3. CD51 expression (EMP51), or; 4. CD54 expression (EMP54). EMP62E- and EMP54-leukocyte conjugates were measured based on the detection of E-selectin or CD54, respectively, coexpressed with CD45 in neutrophils, monocytes and lymphocytes. Results: Results are summarized in Table 1. Levels of free EMP31, EMP51, EMP54 and EMP62E did not differ significantly between the groups. However, a very significant elevation of EMP54-Lymphocyte Conjugates (p=0.001) and a trend towards an elevation of EMP62E-Lymphocyte Conjugates was seen in HIV-infected patients. Furthermore, EMP63E-lymphocyte conjugates significantly correlated with the CD4+ cell count (R=-0.64; p=0.03). Conversely, HIV-infected patients demonstrated significantly lower levels of EMP62E -Monocyte Conjugates (p=0.0005) and a trend toward lower levels of EMP54 -Monocyte Conjugates (p=0.08). Conclusions: HIV infected patients with optimal response to HAART demonstrate an increased number of circulating EMP-lymphocyte conjugates with decreased number of EMP-monocyte conjugates. We speculate that viral EMP-receptor upregulation in lymphocytes and/or downregulation in monocytes could account for this phenomenon. EMP-lymphocyte conjugates inversely correlate with the CD4 count. The role of increased EMP-lymphocyte interactions in viral spread and lymphocyte dysfunction/apoptosis in HIV infected-patients requires further investigation. | | HIV+ Patients | Control | P value | |:---------------------------------------- | ---------------- | ---------------- | ------- | | MFI=Mean fluorescence intensity | | EMP31, counts/μL (IQR) | 680 (497–1112) | 1018 (566-1691) | 0.16 | | EMP51, counts/μL (IQR) | 114 (75–141.5) | 114 (96–143) | 0.59 | | EMP62E, counts/μL (IQR) | 72 (53.5–123.5) | 77 (48–113) | 0.66 | | EMP54, counts/μL (IQR) | 58 (39.5–78.5) | 39 (18–141) | 0.42 | | EMP54-Lymphocyte Conjugates, MFI (IQR) | 1.37 (1.26–1.42) | 1.2 (1.13–1.26) | 0.001 | | EMP54-Monocyte Conjugates, MFI (IQR) | 1.14 (1.05–1.3) | 1.22 (1.16–1.64) | 0.08 | | EMP54-Neutrophil Conjugates, MFI (IQR) | 1.46 (1.27–2.28) | 1.66 (1.28–2.34) | 0.74 | | EMP62E-Lymphocyte Conjugates, MFI (IQR) | 1.15 (1.11–1.19) | 1.13 (1.07–1.18) | 0.13 | | EMP62E -Monocyte Conjugates, MFI (IQR) | 1.17 (1.02–1.19) | 1.31 (1.22–1.56) | 0.0005 | | EMP62E -Neutrophil Conjugates, MFI (IQR) | 1.47 (1.21–2.01) | 1.94 (1.57–2.52) | 0.10 | Levels of endothelial microparticles (EMPs) and EMP-leukocyte conjugates in HIV+ patients compared to controls.

Background: HIV infection and its treatment have been associated with an increased risk of atherothrombotic cardiovascular disease. Little is known about the status of platelets in optimally controlled HIV infection. We aimed to assess the status of platelets using flow cytometry markers of platelet activation/apoptosis in HIV-infected patients who demonstrated an optimal response to highly active antiretroviral therapy (HAART). Methods: In the current study we measured P-selectin expression in platelets, platelet microparticles (PMP) and platelet-leukocyte conjugates (PLC) by flow cytometry in 29 patients (mean age=42.1±7 years) with HIV infection on HAART who demonstrated an optimal viral and immunological response (CD4+ cell count > 200 /mm3 and undetectable viral load by ultrasensitive PCR analysis). Patients with a history of diabetes, smoking, illicit drug use, thrombotic, cardiovascular or malignant disease were excluded. We used age- and gender-matched healthy individuals as controls. PMP were measured by flow cytometry based in the co-expression of CD31 and CD42b. Platelet activation was also assessed by expression of activation marker P-selectin (expressed in fluorescence intensity units, FIU). PLC were measured based on the co-expression of CD45 and CD41 (expressed as percentage of leukocytes positive for CD41). Results: Platelet expression of P-selectin was not significantly different between HIV infected patients (7.35 FIU; IQR=4.00–15.43) and controls (13.32 FIU; IQR=4.91–23.02; p=0.11). However, the levels of PMP were markedly elevated in HIV-infected patients (24,951 (counts/μl; IQR=17,887–36,175) compared to the control group (13,862 counts/μl; IQR=9,984–20,736; p=0.001). The levels of PLC were lower in HIV-infected patients (52.2%; IQR=42.65–65.75) compared to controls (63.8%; IQR=56.9–78.7; p=0.0007). There was a trend for a negative correlation between PMP levels and the CD4 count (Pearson R=−0.34; p=0.07). Conclusions: HIV infected patients with optimal response to HAART demonstrate an increased number of circulating free PMP, normal levels of platelet expression of activation marker P-selectin and decreased levels of PLC. A decreased number of PLC indicates decreased binding of platelets and PMP to leukocytes in HIV-infected patients, which could be partially responsible for increased levels of free PMP. In addition, PMP (unlike P-selectin expression) may be a sensitive marker indicating low-grade platelet activation in HIV infection. Increased PMP levels are likely to contribute to the atherothrombotic risk HIV+ infected patients on HAART.