Differential diagnosis of ST-elevations on EKG
- ST elevation MI!
- Aortic dissection
- Hypertensive crisis
- Aortic stenosis
- Cocaine use
- Early repolarization
- Brugada Syndrome
Differential diagnosis of ST-elevations on EKG
The Deep South region has become the epicenter of the US HIV epidemic. Despite having only 28% of the total US population, nine states in the Deep South account for nearly 40% of national HIV diagnoses. This region has the highest HIV diagnosis rates and the highest number of people living with HIV of any US region based on data for 2008-2011. And new research has found that the five-year survival rate for people diagnosed with HIV or AIDS is lower in the Deep South than in the rest of the country.
So why are we seeing higher death rates and lower survival rates among those living with HIV in the Deep South? The reasons are complicated, but poverty, social stigma, lack of health-care infrastructure and more rural geography likely all play a role.
Recent research by the Centers for Disease Control and Prevention (CDC) and the Southern HIV/AIDS Strategy Initiative (SASI) at Duke University Law School in nine states of the Deep South – Alabama, Florida, Georgia, Louisiana, Mississippi and North and South Carolina, Tennessee and Texas – found that people diagnosed with HIV or AIDS in these states are dying at higher rates than those diagnosed in the rest of the country. This is the case even after controlling for regional differences in age, sex, race, and area population size.
CDC/SASI research found that 27% of people diagnosed with AIDS in the Deep South region in 2003-2004 had died within five years of diagnosis. Although five-year survival varied among states in the Deep South, no state had a survival percentage at or above the US average, 77%. In Louisiana, one-third of people diagnosed with AIDS and 19% of those diagnosed with HIV had died within five years of diagnosis.
Researchers also compared the characteristics of those diagnosed with HIV/AIDS in the Deep South region to national averages and found higher percentages of young people (aged 13-24), blacks, females and transmission attributed to heterosexual contact among the region’s individuals diagnosed with HIV. More than one-quarter of people diagnosed with HIV lived outside a large urban area, which is the highest percentage of any US region.
The Deep South has lower levels of income, education and insurance coverage than the rest of the US. Poverty is consistently associated with poorer health so it is not surprising that the Deep South is experiencing high death rates among those diagnosed with HIV. And none of the Deep South states have accepted federal dollars to expand their Medicaid programs under the Affordable Care Act, leaving thousands of people in the region without health insurance.
Geography also plays a role in the Southern HIV epidemic. Much of the Deep South HIV epidemic is concentrated outside of large urban areas. The CDC/SASI research found that living outside a large urban area at the time of HIV diagnosis significantly predicted greater death rates among people living with HIV in the region.
HIV-related stigma has been found to be higher outside the large urban areas and transportation is a significant barrier to medical care for HIV-positive individuals living outside urban areas since most HIV specialty care is located in urban areas. Without reliable transportation, people miss appointments and may lack access to supportive services such as case management, support groups and legal services.
Thanks to advances in HIV treatment, people who are diagnosed with HIV can have normal life expectancies. But that’s only if they get linked to HIV medical care and remain on treatment, which is a challenge in a region where so many people live outside of urban areas, live in poverty or lack access to health care.
HIV-related stigma has consistently been cited as a driver of the HIV epidemic — especially in the South. In the words of a Deep South focus group participant living with HIV, “HIV doesn’t kill. Stigma kills.”
HIV care providers in the Deep South region tell stories of patients who don’t come to their medical appointments, who won’t participate in support groups, who won’t disclose their HIV status to their closest family members (and the list goes on) because of stigma and a deep fear of how they will be perceived if others discover their status. Stigma also prevents people from getting tested for HIV, which is a critical step in getting the right treatment and in preventing further transmission of the disease.
Southern laws and policies also contribute to stigma. Most Deep South states have abstinence-based sex education in public schools, which has not been shown to be effective in preventing sexually transmitted infections
Many Southern states also criminalize HIV-related sexual behaviors and prohibit syringe exchange programs, thus further marginalizing people at high risk for becoming HIV positive, such as sex workers and injection drug users. These laws also discourage HIV testing and make interventions that have proven effective, like syringe exchange, illegal.
The drivers of the Southern HIV epidemic are complicated and to a great extent mirror the causes of poor health outcomes overall in southern states. Creative programs, such as the expansion of telemedicine programs and the co-location of HIV care with other services, such as case management and mental health and substance abuse care, are important to overcome stigma and the lack of transportation and medical care in non-urban areas.
Funding to support anti-stigma interventions, including empowerment initiatives for those living with HIV and educational efforts for churches and community, is critical. Finally, increased prevention funding that is directed at urban and rural areas alike is crucial if we are to stem the new HIV diagnosis rates and lower the death rates in the Deep South.
Last week, Dr. Chevelle Brudy from the division of General Internal Medicine at UT Southwestern gave a fantastic lecture on the evaluation and management of depression for the internist. Below are the slides – check it out!
Case challenge # 13 presented a 20-year-old white male with fever, conjunctival injection, cervical lymphadenopathy, cracked/red lips, a macular rash, swelling in his hands, a history of tonsillar abscess, and elevated inflammatory markers. Work-up for infectious disease and auto-immune disease are negative.
Changes in extremities: Acute: Erythema and edema of hands and feet Convalescent: Membranous desquamation of fingertips
Bilateral, painless bulbar conjunctival injection without exudate
Changes in lips and oral cavity: Erythema and cracking of lips, strawberry tongue, diffuse injection of oral and pharyngeal mucosae
Cervical lymphadenopathy (≥1.5 cm in diameter), usually unilateral
*Patients with fever and fewer than 4 principal symptoms can be diagnosed as having Kawasaki disease when coronary artery disease is detected by 2-dimensional echocardiography or coronary angiography. Other diagnoses should be excluded. The physician should be aware that some children with illness not fulfilling these criteria have developed coronary artery aneurysms.
Case challenge #14 (aka the Parkland Files!) will be posted next week!
To learn more about this exciting topic and the new advances in the field, check out the following article by Dr. David Johnson and Dr. Schiller!
This week at morning report, Dr. Biff Palmer who is a professor of internal medicine at UT Southwestern in the nephrology division, talked with the housestaff about recent research that has shed light on brown adipose tissue and “beige cells” and their role in metabolism and weight loss. This has gained recent coverage in the media, which many news services have referred to as the “polar vortex diet”. But is there any actual science to this?
YES! Long story short, brown adipose tissue in adults is associated with weight loss as it takes calories from normal fat and burns it. Brown fat plays a key role in thermogenesis and has been a target for weight loss. Scientists have shown that with cold exposure, brown adipose tissue become more metabolically active and may potentially lead to weight loss. White adipose tissue on the other hand functions to store energy as scientists have looked for ways to convert white adipose tissue to brown to enhance metabolism and weight loss. Thus, a third subtype of adipose tissue has been identified called “beige adipocytes” which are white fat cells that express similar genes as brown fat cells, particularly under cold exposure and beta-adrenergic stimulation, and may lead to weight loss. Dr. Ajay Chawla from UCSF recently published a paper in Cell, determining that interleukin 4 and interleukin 13 recruit macrophages to fat leading to catecholamine production and the browning of white fat in mouse models. Studies like this has made this an active area of research for potential targets to treat obesity and maintain weight.
Dr. Palmer recently co-authored a paper looking at the effect of Roux-en-Y gastric bypass on browning in gonadal adipose tissue of female mice and may help offer further insight as to why this surgery leads to weight loss and remediation of type-2-diabetes.The study showed that upregulation of Nppb, Npr1, Npr2, and Beta-3 adrenergic receptors in gonadal adipose tissue following RYGB was associated with increased browning which may lead to those beneficial effects. Check out the study co-authored by Dr. Palmer below as well as a great summary about brown and beige fat cells by Nature by clicking on the links below!
Brown and beige fat: development, function, and therapeutic potential (Nature Medicine)
Photo (AP Photo/Mark Lennihan)
This week, Dr. Eric Steen from the Division of General Internal Medicine at UT Southwestern, gave a fantastic lecture on back pain – evaluation and management of this very common chief complaint. Check out his slides below!
The American College of Physicians has an excellent series called “In the Clinic,” presenting topics to inform the delivery of effective, evidence-based, cost-conscious primary care. Today, we present their thoughts on the management of obstructive sleep apnea – a common condition that we encounter almost daily in our practice. You know the patient needs a sleep study, but which patient? Can you do anything to prevent the development of OSA or reduce its morbidity? Check out the ACP website for guidance (click the image below to link to the article):
Although symptoms occasionally develop after just a few weeks of contact with the allergen, most cases of hypersensitivity pneumonitis occur following months or years of continuous or intermittent inhalation of the inciting agent.
This week, NPR posted an interesting segment titled, “Why Many Doctors Don’t Follow Best Practices”, about why some physicians don’t follow nationally-recognized guidelines despite rigorous research and studies. The segment refers to research by Dr. Catherine Chen from UCSF about preoperative testing for medical clearance in Medicare patients undergoing cataract surgery. Despite studies showing preoperative testing does not decrease adverse events or improve outcomes, her study in this month’s NEJM showed that this practice was still occurring frequently and seemed to be based on physician practice patterns rather than patient characteristics. Should we all follow “best practices”? Or we not taking into account other factors that may not be addressed in these best practices? Check out NPR’s segment by clicking on the link and listening to the segment below!