Pediatric AIDS clinic reports success

Drug protocols and other measures prevent HIV-positive births in New Haven for more than 12 years.

Born HIV-positive, for 20 years “John” relied on the Yale Pediatric AIDS Clinic to keep him healthy. That meant visits every three months and treatment that was literally hard to swallow. But John says he “loved every minute” of his time at the clinic because he could rely on the staff, even when the problem was not medical. For example, the clinic helped him find housing as a teen when his mother left the state.

Now a junior at Southern Connecticut State University, he is making plans for graduate school. He calls to let everyone at the clinic know what’s going on in his life, but he gets his HIV care at an adult clinic, where he is likely to visit three times a year. Increasingly sophisticated blood testing lets doctors fine-tune his medications to prevent resistance to antiretrovirals.

As patients like John transition into adult care, few new cases replace them. No woman known to be HIV-positive has passed on the virus to her baby in New Haven since 1996. The protocols for preventing mother-to-child transmission are so effective that the only HIV-positive infants delivered in the city over the past 13 years were born to mothers who had not been not diagnosed themselves.

“We have literally been putting ourselves out of work,” said Warren A. Andiman, M.D., FW ’76, professor of pediatrics and epidemiology and public health, and medical director of the Pediatric AIDS Program. An infectious disease specialist, Andiman began caring for HIV-positive infants in 1982. In the first few years, his young patients died protracted and miserable deaths, often by age 6. “There’s no way to describe what it was like,” he said.

Today mother-to-child transmission is a rarity in the developed world. Nationwide, the rate is less than 2 percent, which Andiman attributes to “will and money.”

Widespread HIV testing allows doctors to identify women who may pass the virus on to their babies. Any HIV-positive pregnant woman in the area gets referred to Yale’s High-Risk Maternity Program or a parallel program at the Hospital of St. Raphael, both of which work closely with the Pediatric AIDS Program. Such measures as giving mothers antiretrovirals during the pregnancy and administering AZT to mothers during labor and to newborns have proven successful, along with, in certain circumstances, performing caesarean sections and discouraging breast feeding.

Connecticut mandates that every pregnant woman be offered HIV testing twice. She can be offered testing again during labor. If she refuses, a newborn can be tested over her objections. In practice, almost all the mothers welcome testing.

During an HIV-positive woman’s pregnancy, older children or sex partners may be diagnosed and get treatment. The woman will be connected with the adult AIDS clinic and social workers will address a wide range of practical and emotional issues. “It’s a sort of seminal period, a moment when all kinds of worthwhile stuff can happen,” said Andiman.

So much good stuff has happened at the Pediatric AIDS Clinic that Andiman expects it to close in the next couple of years. The few remaining patients can be transitioned to the Pediatric Infectious Disease Clinic. “AIDS is an infectious disease just like many other infectious diseases,” Andiman said.

—Colleen Shaddox

A revitalized trauma section increases staff and improves care in emergency cases

On February 16, 2007, Quinnipiac University senior Benjamin Shapiro was driving down a secondary road in Hamden, Conn., at about 1 a.m. when his car slid across four lanes of traffic, crashed through a chain-link fence, flipped over a concrete barrier, slid down an embankment and landed in the Mill River. He spent the next 20 minutes submerged in icy water.

“When they pulled him out of the water there was no heartbeat, no pulse, nothing,” said Shapiro’s stepmother, Joan Abrams. Shapiro had suffered a brain injury, the bones in the left side of his face were crushed and his left eyeball was hanging by a tendon. Doctors put his chances of survival at well below 10 percent.

The Department of Surgery’s Section of Trauma, Surgical Critical Care and Surgical Emergencies, which was recently revamped under the direction of Kimberly A. Davis, M.D., was prepared to deal with an emergency of this magnitude.

“Everyone who is a full-time member of this section is board-certified or eligible in both general surgery and surgical critical care,” said Davis, who took over as section chief in June 2006. “With attending-level surgeons in the hospital at all times, we can take care of anything that comes our way, 24/7.” This also means faster evaluation and response times and improved communications between caregivers as well as with family members.

“With Kim’s appointment, our Level 1 trauma center has become a comprehensive acute care service, where physicians are able to function in all three areas: urgent general surgery, critical care and trauma, and that has made a huge difference in our service to the community,” said Tucker Leary, vice president of administration at the hospital.

Under Davis, the number of surgeons has nearly doubled, to seven full-time surgeons providing trauma, critical care and emergency surgery. Davis is planning to fill an eighth position soon. She also initiated a weekly meeting to review cases and discuss what worked and what might have been handled differently.

And the investment is paying off. The year before Davis’ arrival, the section evaluated 2,550 patients and admitted 1,650. In 2007-2008, 3,800 trauma patients were evaluated and 2,400 were admitted. The survival rate of trauma center patients is 95.6 percent, above the national average of 94 percent.

One of those survivors is Shapiro, who spent nine days in a medically induced coma, followed by surgery to rebuild his face and save his eye. He was able to return to Quinnipiac as a full-time student and graduated with his class that May.

“I look back on the day of my accident and as horrible as it was, I view it as the single best day of my life,” he said. “Now, whenever someone says to me, ‘How are you doing?’ I can always say, ‘Great.’”

—Jennifer Kaylin

et cetera

Lost in translation

Even as the number of Americans with limited English-language proficiency has continued to grow, many physicians try to get by with their own limited foreign-language skills or by relying on a patient’s friend or family member, according to research conducted in part by the School of Public Health.

The study, published online in the Journal of General Internal Medicine in December, found that increasing the use of interpreters by hospital physicians will require “substantial” changes in hospital practice. “Residents found it difficult to change their practice, despite misgivings about the quality of care provided,” said Lisa Diamond, M.D., M.P.H., a Robert Wood Johnson Foundation Clinical Scholar and lead author of the study, who is now at the Palo Alto Medical Foundation Research Institute in California. Research has shown that language barriers can lead to decreased access to preventive services, poor understanding of instructions for medications, longer hospital stays and an increased risk of medical errors and misdiagnoses.

—John Curtis

Elderly want say in treatment

Elderly patients with multiple medical conditions want to be involved in their treatment decisions, Yale researchers reported in the Journal of the American Geriatrics Society in October.

About 65 percent of older Medicare beneficiaries have at least two chronic conditions, and 24 percent have four or more. These patients face what are called “competing outcomes”—complex choices presented when the treatment for one condition could worsen another. Medicine for elevated cholesterol, for example, may cause leg cramps that prevent a patient from doing exercises that reduce arthritis symptoms.

Study author Terri R. Fried, M.D., associate professor of medicine (geriatrics), and her team conducted 13 focus groups with 66 people age 65 and older who had an average of five chronic conditions and took an average of seven medications. When faced with competing outcomes, Fried said, “They chose the treatment option that would maximize the likelihood of their most desired outcome.”

—J.C.


			Originally published in Yale Medicine, Spring 2009. Copyright © 2009 Yale University School of Medicine. All rights reserved.