Publications by authors named "Jessica Robinson-Papp"

48 Publications

HIV in the Brain: From Devastating Dementia to White Matter Hyperintensities.

Neurology 2021 Feb 26. Epub 2021 Feb 26.

Department of Neurology Johns Hopkins University School of Medicine, Baltimore, MD.

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http://dx.doi.org/10.1212/WNL.0000000000011735DOI Listing
February 2021

Severe rapidly progressive Guillain-Barré syndrome in the setting of acute COVID-19 disease.

J Neurovirol 2020 10 27;26(5):797-799. Epub 2020 Jul 27.

Division of Neuromuscular Diseases and Clinical Neurophysiology Laboratories, Department of Neurology, Icahn School of Medicine, Mount Sinai Hospital, 1468 Madison Avenue, New York, NY, 10029, USA.

There is concern that the global burden of coronavirus disease of 2019 (COVID-19) due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection might yield an increased occurrence of Guillain-Barré syndrome (GBS). It is currently unknown whether concomitant SARS-CoV-2 infection and GBS are pathophysiologically related, what biomarkers are useful for diagnosis, and what is the optimal treatment given the medical comorbidities, complications, and simultaneous infection. We report a patient who developed severe GBS following SARS-CoV-2 infection at the peak of the initial COVID-19 surge (April 2020) in New York City and discuss diagnostic and management issues and complications that may warrant special consideration in similar patients.
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http://dx.doi.org/10.1007/s13365-020-00884-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384559PMC
October 2020

Validation of the Safer Opioid Prescribing Evaluation Tool (SOPET) for Assessing Adherence to the Centers for Disease Control Opioid Prescribing Guidelines.

Pain Med 2020 12;21(12):3655-3659

Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objective: In response to the opioid epidemic, the Centers for Disease Control and Prevention issued guidelines (CDCG) in 2016 for the prescription of opioids for chronic pain. To facilitate research into whether CDCG implementation will lead to reductions in opioid prescribing and improved patient safety, we sought to validate a tool that quantifies CDCG adherence based on clinical documentation.

Design: The Safe Opioid Prescribing Evaluation Tool (SOPET) was developed in four phases as part of a study to improve the implementation of the CDCG in the clinical setting. Four raters with varying levels of clinical experience and expertise were trained to use the SOPET and then used it to evaluate 21 baseline patient encounters. Intraclass correlation coefficient (ICC) estimates and their 95% confident intervals (CIs) were calculated for the total SOPET score based on a mean-rating (k = 4), absolute-agreement, two-way random-effects model. For intrarater reliability, two-way mixed-effect models were used.

Results: Inter-rater reliability was good, with an average-measures ICC of 0.82 (95% CI = 0.63-0.92). Intrarater reliability was excellent for the three raters, who were MDs, with average-measures ICCs as follows: 0.92 (95% CI = 0.81-0.97), 0.97 (95% CI = 0.92-0.99), 0.99 (95% CI = 0.99-0.99). However, the intrarater reliability for the non-MD rater was lower 0.69 (95% CI = 0.22-0.88).

Conclusions: Overall, the SOPET is useful for evaluating implementation of the CDCG in clinical documentation. It is an important first step in the design of future studies assessing whether adherence to the CDCG improves patient safety outcomes.
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http://dx.doi.org/10.1093/pm/pnaa138DOI Listing
December 2020

Patient recommendations for opioid prescribing in the context of HIV care: findings from a set of public deliberations.

AIDS Care 2020 11 23;32(11):1471-1478. Epub 2019 Dec 23.

Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

It is widely acknowledged that the growing opioid epidemic and associated increase in overdose deaths necessitates a reexamination of processes and procedures related to an opioid prescription for the treatment of chronic pain. However, the perspectives of patients, including those at the highest risk for opioid-related harms, are largely missing from this reexamination. To partially address the gap, we conducted a pair of one-day public deliberations on opioid prescribing in the context of HIV care. Results included recommendations and perspectives from people living with HIV that detail how providers can best assess patient needs, communicate regarding opioids, and reduce the risk of misuse. Participants emphasized the importance of building trust with patients and taking an extensive patient history prior to making decisions about whether to initiate or end an opioid prescription. This trust - together with an understanding of the origin of a patient's pain, history of drug use and other therapies tried - was perceived as essential to effective monitoring and pain management, as well as promotion of positive health outcomes. Ensuring that such patient perspectives are incorporated into the operationalization of guidelines for safe opioid prescribing may help to improve outcomes and quality of care for people living with HIV.
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http://dx.doi.org/10.1080/09540121.2019.1705962DOI Listing
November 2020

What physicians need to implement safer opioid prescribing: A qualitative study.

J Opioid Manag 2019 Nov/Dec;15(6):479-485

Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York.

Introduction: In response to the US opioid epidemic, the Centers for Disease Control and Prevention issued a guideline (CDCG) for prescribing opioids for chronic pain. Successful implementation of the CDCG requires identification of the information, skills, and support physicians need to carry out its recommendations. However, such data are currently lacking.

Methods: The authors performed one-on-one interviews with nine practicing physicians regarding their needs and perspectives for successful CDCG implementation, including the perceived barriers, focusing on communication strategies. Interviews were audio recorded, transcribed, and a thematic qualitative analysis was performed.

Findings: Three major themes were identified: communication, knowledge, and information technology (IT). Physicians reported that open communication with patients about opioids was difficult and burdensome, but essential; they shared their communication strategies. Knowledge gaps included patient-specific topics (eg, availability of/insurance coverage for non-opioid treatments) and more general areas (eg, opioid dosing/equivalencies, prescribing naloxone). Finally, physicians discussed the importance of innovation in IT, focusing on the electronic medical record for decision support and to allow safer opioid prescribing within the time constraints of clinical practice.

Discussion: These qualitative data document practical issues that should be considered in the development of implementation plans for safer opioid prescribing practices. Specifically, healthcare systems may need to provide opioid-relevant communication strategies and training, education on key topics such as naloxone prescribing, resources for referrals to appropriate nonpharmacologic treatments, and innovative IT solutions. Future research is needed to establish that such measures will be effective in producing better outcomes for patients on opioids for chronic pain.
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http://dx.doi.org/10.5055/jom.2019.0538DOI Listing
January 2020

Decreasing risk among HIV patients on opioid therapy for chronic pain: Development of the TOWER intervention for HIV care providers.

Contemp Clin Trials Commun 2019 Dec 12;16:100468. Epub 2019 Oct 12.

Icahn School of Medicine at Mount Sinai, Department of Population Health Science and Policy, USA.

Many people with HIV (PWH) experience chronic pain that limits daily function and quality of life. PWH with chronic pain have commonly been prescribed opioids, sometimes for many years, and it is unclear if and how the management of these legacy patients should change in light of the current US opioid epidemic. Guidelines, such as the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain (CDCG), provide recommendations for the management of such patients but have yet to be translated into easily implementable interventions; there is also a lack of strong evidence that adhering to these recommendations improves patient outcomes such as amount of opioid use and pain levels. Herein we describe the development and preliminary testing of a theory-based intervention, called TOWER (ard Saf Opioid Prescribing), designed to support HIV primary care providers in CDCG-adherent opioid prescribing practices with PWH who are already prescribed opioids for chronic pain. TOWER incorporates the content of the CDCG into the theoretical and operational framework of the Information Motivation and Behavioral Skills (IMB) model of health-related behavior. The development process included elicitation research and incorporation of feedback from providers and PWH; testing is being conducted via an adaptive feasibility clinical trial. The results of this process will form the basis of a large, well-powered clinical trial to test the effectiveness of TOWER in promoting CDCG-adherent opioid prescribing practices and improving outcomes for PWH with chronic pain.
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http://dx.doi.org/10.1016/j.conctc.2019.100468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831717PMC
December 2019

Characteristics of Motor Dysfunction in Longstanding Human Immunodeficiency Virus.

Clin Infect Dis 2020 Sep;71(6):1532-1538

Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background: Cognitive dysfunction in human immunodeficiency virus (HIV) has decreased, but milder forms of HIV-associated neurocognitive disorders (HAND) persist along with motor dysfunction. The HIV Motor Scale (HMS) is a validated tool that captures motor abnormalities on routine neurologic examination and which is associated with cognitive impairment in HIV. In this study, we applied a modified HMS (MHMS) to a nationwide cohort of people with longstanding HIV to characterize and understand the factors contributing to motor dysfunction.

Methods: The National NeuroAIDS Tissue Consortium is a nationwide longitudinal cohort study. Participants undergo regular assessments including neurological examination, neuropsychological testing, and immunovirologic data collection. Data from examinations were used to calculate the MHMS score, which was then correlated with history of AIDS-related central nervous system (CNS) disorders (ARCD; eg, prior CNS opportunistic infection), cerebrovascular disease (CVD), and HAND.

Results: Sixty-nine percent of participants showed an abnormality on the MHMS, with 27% classified as severe. Results did not vary based on demographic or immunologic variables. The most common abnormalities seen were gait (54%), followed by coordination (39%) and strength (25%), and these commonly co-occurred. CVD (P = .02), history of ARCD (P = .001), and HAND (P = .001) were all associated with higher (ie, worse) HMS in univariate analyses; CVD and ARCD persisted in multivariate analyses. CVD was also marginally associated with symptomatic HAND.

Conclusions: Complex motor dysfunction remains common in HIV and is associated with CVD, ARCD, and to a lesser extent, HAND. Future studies are needed to understand the longitudinal trajectory of HIV-associated motor dysfunction, its neural substrates, and impact on quality of life.
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http://dx.doi.org/10.1093/cid/ciz986DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7486845PMC
September 2020

Frailty in medically complex individuals with chronic HIV.

AIDS 2019 08;33(10):1603-1611

Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA.

Objectives: Multimorbidity and frailty are consequences of aging with HIV, yet not everyone with medical disease is frail. Our objective was to identify factors associated with frailty in a multimorbid HIV-infected cohort.

Design: Analysis of a prospective, observational, longitudinal cohort.

Methods: Three hundred and thirty-two participants in the medically advanced National NeuroAIDS Tissue Consortium (NNTC) study were categorized as frail, prefrail, or robust with the Fried Frailty Index. A series of logistic regression analyses (first univariate, then multivariable) were conducted to determine whether medical comorbidities, immunologic and virologic parameters, and/or neuropsychiatric variables predicted increased odds of frailty.

Results: The mean number of medical comorbidities per participant was 2.7, mean CD4 T-cell count was 530 cells/μl, and 77% had undetectable HIV RNA in blood. Twenty-two percent were frail, 55% prefrail, and 23% robust. Significant predictors of frailty in multivariable analysis were cognitive diagnosis rendered by Frascati criteria, depressive symptoms, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and sex. Men were less likely to be frail than women. Higher odds of frailty were seen with: symptomatic, but not asymptomatic, cognitive impairment (compared with cognitive normals); more depressive symptoms; diabetes mellitus; and COPD.

Conclusion: Neuropsychiatric illness increased odds of being frail on a predominantly physical/motoric measure, but only when symptomatic. Lack of association with asymptomatic impairment may reflect the importance of functional limitation to frailty, or possibly a unique resilience phenotype. Understanding why sex and symptomatic neuropsychiatric illness are associated with frailty will be important in managing HIV-associated morbidity in aging populations.
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http://dx.doi.org/10.1097/QAD.0000000000002250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6760300PMC
August 2019

The effect of pyridostigmine on small intestinal bacterial overgrowth (SIBO) and plasma inflammatory biomarkers in HIV-associated autonomic neuropathies.

J Neurovirol 2019 08 16;25(4):551-559. Epub 2019 May 16.

Department Neurology, Icahn School of Medicine at Mount Sinai, Box 1052, One Gustave L. Levy Place, New York, NY, 10029, USA.

Small intestinal bacterial overgrowth (SIBO) is common among patients with HIV-associated autonomic neuropathies (HIV-AN) and may be associated with increased bacterial translocation and elevated plasma inflammatory biomarkers. Pyridostigmine is an acetylcholinesterase inhibitor which has been used to augment autonomic signaling. We sought preliminary evidence as to whether pyridostigmine could improve proximal gastrointestinal motility, reduce SIBO, reduce plasma sCD14 (a marker of macrophage activation and indirect measure of translocation), and reduce the inflammatory cytokines IL-6 and TNFα in patients with HIV-AN. Fifteen participants with well-controlled HIV, HIV-AN, and SIBO were treated with 8 weeks of pyridostigmine (30 mg PO TID). Glucose breath testing for SIBO, gastric emptying studies (GES) to assess motility, plasma sCD14, IL-6, and TNFα, and gastrointestinal autonomic symptoms were compared before and after treatment. Thirteen participants (87%) experienced an improvement in SIBO following pyridostigmine treatment; with an average improvement of 50% (p = 0.016). There was no change in gastrointestinal motility; however, only two participants met GES criteria for gastroparesis at baseline. TNFα and sCD14 levels declined by 12% (p = 0.004) and 19% (p = 0.015), respectively; there was no significant change in IL-6 or gastrointestinal symptoms. Pyridostigmine may ameliorate SIBO and reduce levels of sCD14 and TNFα in patients with HIV-AN. Larger placebo-controlled studies are needed to definitively delineate how HIV-AN affects gastrointestinal motility, SIBO, and systemic inflammation in HIV, and whether treatment improves clinical outcomes.
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http://dx.doi.org/10.1007/s13365-019-00756-9DOI Listing
August 2019

Motor function declines over time in human immunodeficiency virus and is associated with cerebrovascular disease, while HIV-associated neurocognitive disorder remains stable.

J Neurovirol 2018 08 25;24(4):514-522. Epub 2018 Apr 25.

Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1052, New York, NY, 10029, USA.

HIV-associated neurocognitive disorders (HAND) remain prevalent in the combined antiretroviral therapy (CART) era, especially the milder forms. Despite these milder phenotypes, we have shown that motor abnormalities persist and have quantified them with the HIV Dementia Motor Scale (HDMS). Our objectives were to replicate, in an independent sample, our prior findings that the HDMS is associated with cognitive impairment in HIV, while adding consideration of age-associated comorbidities such as cerebrovascular disease, and to examine the longitudinal trajectories of cognitive and motor dysfunction. We included all participants enrolled in the Manhattan HIV Brain Bank (MHBB) from January 2007 to May 2017 who had complete baseline data (N = 164). MHBB participants undergo standardized longitudinal assessments including documentation of comorbidities and medications, blood work, the HDMS, and neurocognitive testing. We found that motor dysfunction, cognitive impairment, and cerebrovascular disease were significantly associated with each other at baseline. Cerebrovascular disease independently predicted cognitive impairment in a multivariable model. Longitudinal analysis in a subset of 78 participants with ≥ 4 years of follow-up showed a stable cognition but declining motor function. We conclude that the HDMS is a valid measurement of motor dysfunction in HIV-infected patients and is associated with cognitive impairment and the presence of cerebrovascular disease. Cognitive impairment is mild and stable in CART-treated HIV; however, motor function declines over time, which may be related to the accrual of comorbidities such as cerebrovascular disease. Further research should examine the mechanisms underlying motor dysfunction in HIV and its clinical impact.
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http://dx.doi.org/10.1007/s13365-018-0640-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309169PMC
August 2018

Vagal dysfunction and small intestinal bacterial overgrowth: novel pathways to chronic inflammation in HIV.

AIDS 2018 06;32(9):1147-1156

Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objective: Chronic inflammation in HIV-infected individuals drives disease progression and the development of comorbidities, despite viral suppression with combined antiretroviral therapy. Here, we sought evidence that vagal dysfunction, which occurs commonly as part of HIV-associated autonomic neuropathy, could exacerbate inflammation through gastrointestinal dysmotility, small intestinal bacterial overgrowth (SIBO), and alterations in patterns of soluble immune mediators.

Design: This is a cross-sectional observational study.

Methods: Forty participants on stable combined antiretroviral therapy with gastrointestinal symptoms, and no causes for vagal or gastrointestinal dysfunction other than HIV, underwent autonomic testing, hydrogen/methane breath testing for SIBO, and gastric emptying scintigraphy. A panel of 41 cytokines, high-mobility group box 1, and markers of bacterial translocation (lipopolysaccharide) and monocyte/macrophage activation (sCD14 and sCD163) were tested in plasma.

Results: We found that participants with vagal dysfunction had delayed gastric emptying and higher prevalence of SIBO. SIBO was associated with IL-6, but not sCD14; lipopolysaccharide could not be detected in any participant. We also found alteration of cytokine networks in participants with vagal dysfunction, with stronger and more numerous positive correlations between cytokines. In the vagal dysfunction group, high mobility group box 1 was the only soluble mediator displaying strong negative correlations with other cytokines, especially those cytokines that had numerous other strong positive correlations.

Conclusion: The current study provides evidence that the vagal component of HIV-associated autonomic neuropathy is associated with changes in immune and gastrointestinal function in individuals with well treated HIV. Further study will be needed to understand whether therapies targeted at enhancing vagal function could be of benefit in HIV.
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http://dx.doi.org/10.1097/QAD.0000000000001802DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5945300PMC
June 2018

Lower-extremity Dynamometry as a Novel Outcome Measure in a Double-blind, Placebo-controlled, Feasibility Trial of Intravenous Immunoglobulin (IVIG) for HIV-associated Myelopathy.

Innov Clin Neurosci 2018 Feb;15(1-2):28-32

Drs. Robinson-Papp, George, Nmashie and Simpson are with the Department of Neurology.

: Open-label data suggest that intravenous immunoglobulin (IVIG) might improve lower-extremity strength in human immunodeficiency virus (HIV)-associated myelopathy (HIVM), a rare but debilitating neurologic complication of HIV. We sought to determine the feasibility of testing the efficacy of IVIG for HIVM more rigorously. : We conducted a randomized, double-blind, placebo-controlled feasibility trial of IVIG for HIVM, using dynamometry as an outcome measure (Clinical Trial No. NCT01561755). : The study took place in an academic medical center in New York, New York : Only 12 participants were enrolled in four years; critical impediments to the study were the rarity of patients with new HIVM diagnoses and prior exposure to IVIG in patients with an established diagnosis. : Dynamometry of hip flexion, knee flexion, and ankle dorsiflexion were measured; the HIV Dementia Motor Score (HDMS); and the two-minute timed walk test were utilized. : Recruitment was the major feasibility issue. Dynamometry was generally well-tolerated, had good test-retest reliability (=0.71-0.86, <0.02 for all muscle groups), and good inter-item reliability as judged by the correlations between the muscle groups (=0.76-0.81, =0.001-0.005). Dynamometry was valid and clinically meaningful based on its correlations with the HDMS and the two-minute timed walk test. : We conclude that an adequately powered clinical trial of IVIG for HIVM would likely require a prolonged recruitment period and multiple participating sites. Lower limb dynamometry is a useful outcome measure for HIVM, which might also be useful in other HIV-related gait disorders.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819718PMC
February 2018

Comorbid Pain Syndromes in HIV-Associated Peripheral Neuropathy.

Pain Med 2018 07;19(7):1445-1450

Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objective: Peripheral neuropathy (PN) is a common complication of HIV. There is increasing awareness that some forms of PN, particularly small-fiber neuropathies, can be associated with chronic widespread pain syndromes. Given the high prevalence of both PN and chronic pain in HIV, we sought to determine whether patients with a diagnosis of HIV-PN were more likely to experience other chronic pain syndromes.

Methods: Data were obtained from the Clinical Data Warehouse maintained by our institution. All HIV-infected patients receiving standard of care antiretroviral therapy in our institution's primary care HIV clinic (N = 638) were included. Diagnoses of HIV-PN and other chronic pain disorders were established based on clinician-assigned ICD-9/10 codes.

Results: Sixty-eight patients (11%) had a diagnosis of HIV-PN. Patients with HIV-PN were more than twice as likely to have other chronic pain disorders (66% vs 32%, χ2 = 30.3, P < 0.001). Patients with HIV-PN were also older and more likely to have substance use and psychiatric disorders; however, the association of HIV-PN with other chronic pain disorders persisted after adjusting for relevant confounders (χ2(5) = 81.38, P < 0.001).

Conclusions: Patients with HIV-PN commonly experience other chronic pain disorders. Clinicians managing HIV-PN should seek a broad understanding of patients' pain experience as this may alter management strategies. Researchers studying HIV-PN should consider how the presence of other pain disorders might affect outcomes.
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http://dx.doi.org/10.1093/pm/pnx129DOI Listing
July 2018

The Use of Visual Rating Scales to Quantify Brain MRI Lesions in Patients with HIV Infection.

J Neuroimaging 2018 03 21;28(2):217-224. Epub 2017 Aug 21.

Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY.

Background And Purpose: Human immunodeficiency virus (HIV)-infected patients commonly have abnormalities in cerebral white matter that are visible on magnetic resonance imaging (MRI) as hyperintensities (WMHs). Visual rating scales (VRSs) have been used to quantify WMH in other diseases such as cerebral small vessel disease (CSVD), but not in HIV. Such scales are advantageous because they are applicable to routinely acquired MRIs and so are suitable for large-scale studies and clinical care. We sought to establish the utility of three VRSs (the Fazekas, Scheltens, and van Sweiten scales) in HIV.

Methods: The Manhattan HIV Brain Bank (MHBB) is a longitudinal cohort study that performs serial neurologic examinations and neuropsychological testing. All brain MRIs (n = 73) performed for clinical purposes on MHBB participants were scored using the three VRSs. We assessed reliability, validity, and correlation of the VRS with clinical factors relevant to HIV and CSVD.

Results: The VRSs all showed acceptable internal consistency and interrater reliability and were highly correlated with one another (r = 0.836-0.916, P < .001). The Fazekas and Scheltens scales demonstrated more WMH in periventricular regions, and the Scheltens scale also suggested a frontal to occipital gradient, with greater WMH frontally. All three VRSs correlated significantly with cognitive impairment (global T score). Age and hepatitis C virus antibody serostatus were the strongest clinical/demographic correlates of WMH, followed by African-American race.

Conclusions: VRSs reliably quantify WMH in HIV-infected individuals and correlate with cognitive impairment. Future studies may find routinely acquired brain MRI quantified by VRS to be an accessible and meaningful neurologic outcome measure in HIV.
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http://dx.doi.org/10.1111/jon.12466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821603PMC
March 2018

Assessing mNIS+7 and international neurologists' proficiency in a familial amyloidotic polyneuropathy trial.

Muscle Nerve 2017 Nov 7;56(5):901-911. Epub 2017 Apr 7.

Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA.

Introduction: Polyneuropathy signs (Neuropathy Impairment Score, NIS), neurophysiologic tests (m+7 ), disability, and health scores were assessed in baseline evaluations of 100 patients entered into an oligonucleotide familial amyloidotic polyneuropathy (FAP) trial.

Methods: We assessed: (1) Proficiency of grading neurologic signs and correlation with neurophysiologic tests, and (2) clinometric performance of modified NIS+7 neurophysiologic tests (mNIS+7 ) and its subscores and correlation with disability and health scores.

Results: The mNIS+7 sensitively detected, characterized, and broadly scaled diverse polyneuropathy impairments. Polyneuropathy signs (NIS and subscores) correlated with neurophysiology tests, disability, and health scores. Smart Somatotopic Quantitative Sensation Testing of heat as pain 5 provided a needed measure of small fiber involvement not adequately assessed by other tests.

Conclusions: Specially trained neurologists accurately assessed neuropathy signs as compared to referenced neurophysiologic tests. The score, mNIS+7 , broadly detected, characterized, and scaled polyneuropathy abnormality in FAP, which correlated with disability and health scores. Muscle Nerve 56: 901-911, 2017.
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http://dx.doi.org/10.1002/mus.25563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5500439PMC
November 2017

Capsaicin 8% Patch in Painful Diabetic Peripheral Neuropathy: A Randomized, Double-Blind, Placebo-Controlled Study.

J Pain 2017 01 13;18(1):42-53. Epub 2016 Oct 13.

Analgesic Solutions, Natick, Massachusetts; Department of Anesthesiology, Tufts University School of Medicine, Boston, Massachusetts.

This 12-week study evaluated the efficacy and safety of capsaicin 8% patch versus placebo patch in painful diabetic peripheral neuropathy (PDPN). Patients aged 18 years or older with PDPN were randomized (1:1) to one 30-minute treatment (capsaicin 8% patch or placebo patch) to painful areas of the feet. Overall, 369 patients were randomized (capsaicin 8% patch, n = 186; placebo patch, n = 183). Percentage reduction in average daily pain score from baseline to between weeks 2 through 8 (the primary end point) was statistically significant for capsaicin 8% patch versus placebo (-27.4% vs -20.9%; P = .025); improvements in pain were observed from week 2 onward. Versus placebo, patients treated with capsaicin 8% patch had a shorter median time to treatment response (19 vs 72 days) and modest improvements in sleep interference scores from baseline to between weeks 2 through 8 (P = .030) and weeks 2 through 12 (P = .020). Apart from application site reactions, treatment-emergent adverse events were similar between groups. No indications of deterioration in sensory perception of sharp, cold, warm, or vibration stimuli were observed. In patients with PDPN, capsaicin 8% patch treatment provided modest pain relief and sleep quality improvements versus a placebo patch, similar in magnitude to other treatments with known efficacy, but without systemic side effects or sensory deterioration.

Perspective: To our knowledge, this is the first study of the capsaicin 8% patch versus placebo in patients with PDPN to show that one 30-minute capsaicin treatment provides modest improvements in pain and sleep quality. Results confirm the clinical utility of the capsaicin 8% patch in the diabetic population.
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http://dx.doi.org/10.1016/j.jpain.2016.09.008DOI Listing
January 2017

Assessment of autonomic symptoms in a medically complex, urban patient population.

Clin Auton Res 2017 02 12;27(1):25-29. Epub 2016 Oct 12.

Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1052, New York, NY, 10029, USA.

Purpose: Urban, minority communities are disproportionately affected by the chronic diseases associated with autonomic neuropathy; however validated measures of autonomic symptoms have not been studied in these complex populations. We sought to validate the Autonomic Symptom Profile (ASP) in a low income, medically complex, urban patient population.

Methods: Ninety-seven adults were recruited from the outpatient neurology clinic of an academic medical center serving the East Harlem neighborhood of New York City. Participants completed the ASP, and underwent a comprehensive neurologic examination, and a standardized battery of autonomic function tests (quantitative sweat testing, heart rate response to deep breathing (HRDB), Valsalva maneuver, and tilt table). Burden of chronic disease was summarized using the Charlson co-morbidity index (CCI), and detailed medication history was obtained.

Results: The ASP displayed good internal consistency (Cronbach's α = .88), even among lower literacy participants. In univariate analyses, the ASP was correlated with HRDB (r = -.301, p = .002), a marker of cardiac autonomic neuropathy, with the CCI (r = .37, p < .001), and with use of medications with autonomic effects [t(95) = -2.13, p = .036]. However, in multivariate analysis, only the CCI remained significant.

Conclusions: In this urban, predominantly minority patient population, the symptoms captured by the ASP were more closely associated with burden of medical disease than with autonomic dysfunction. Due to this lack of specificity, it is essential that results from autonomic questionnaires be interpreted in the context of the neurologic history and exam, burden of co-morbid illness and medications, and most importantly autonomic function tests.
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http://dx.doi.org/10.1007/s10286-016-0384-4DOI Listing
February 2017

Patient reported outcome measures of pain intensity: Do they tell us what we need to know?

Scand J Pain 2016 04 9;11:73-76. Epub 2016 Jan 9.

Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Objective: To determine the relationship between chronic pain patients' responses to self-report measures of pain intensity, and self-reported strategies when completing such measures.

Participants: Ambulatory outpatients suffering from one of the following chronic pain conditions: painful HIV neuropathy, painful diabetic neuropathy, chronic Low-Back Pain.

Method: As part of a previously reported study using qualitative methods, participants completed standard pain intensity questionnaires as well as a measure of pain related disturbances in activities of daily living. In the previous study, participants' responses during a focus group were then used to identify their strategies and beliefs about their approach to completing the questionnaires. Among the beliefs were: (1) difficulties averaging pain over different time periods (i.e., "what was your average pain during the last 24h" versus "what was your average pain during the last 2 weeks"); (2) difficulty in comparing pain from different etiologies; (3) difficulties in reporting sensations of pain in a manner unaffected by issues and situations secondary to the pain experience, such as difficulties in activities of daily living. In the present paper we use ANOVA (analysis of variance) and partial correlation to determine whether the qualitatively derived perceptions are reflected in the quantitative pain intensity scores.

Results: Participants' belief that it was difficult to "average" pain intensity over different time periods was supported. The data do not support their belief that pain intensity scores are affected by other factors: their specific pain diagnosis, and the extent to which pain interfered with their activities of daily living.

Conclusions: (1) Patients tend to report different levels of pain intensity when asked to report their pain over different periods; (2) insofar as it can be said to exist, the relationship between measures of intensity and interference with activities of daily living is minimal; (3) participants tend to report similar levels of pain intensity, irrespective of etiology.

Implications: (1) Chronic pain patients' elicited beliefs and strategies concerning how they complete pain intensity questionnaires are sometimes, but not invariably, reflected in their responses to these measures. Thus, purely qualitative methodologies alone cannot provide completely reliable information and point to the need to use a "mixed methods" approach combining both qualitative and quantitative data; (2) the lack of association between pain intensity measures and interference with activities of daily living, as well as relative insensitivity to different etiologies underlines the problem in relying on pain intensity measures as the primary means of evaluating the success of a treatment, either for pain management or in clinical research.
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http://dx.doi.org/10.1016/j.sjpain.2015.12.004DOI Listing
April 2016

Chronic pain disorders in HIV primary care: clinical characteristics and association with healthcare utilization.

Pain 2016 Apr;157(4):931-937

Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA Mount Sinai Data Warehouse, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Chronic pain is common in HIV, but incompletely characterized, including its underlying etiologies, its effect on healthcare utilization, and the characteristics of affected patients in the HIV primary care setting. These data are needed to design and justify appropriate clinic-based pain management services. Using a clinical data warehouse, we analyzed one year of data from 638 patients receiving standard-of-care antiretroviral therapy in a large primary care HIV clinic, located in the Harlem neighborhood of New York City. We found that 40% of patients carried one or more chronic pain diagnoses. The most common diagnoses were degenerative musculoskeletal disorders (eg, degenerative spinal disease and osteoarthritis), followed by neuropathic pain and headache disorders. Many patients (16%) had multiple chronic pain diagnoses. Women, older patients, and patients with greater burdens of medical illness, and psychiatric and substance use comorbidities were disproportionately represented among those with chronic pain diagnoses. Controlling for overall health status, HIV patients with chronic pain had greater healthcare utilization including emergency department visits and radiology procedures. In summary, our study demonstrates the high prevalence of chronic pain disorders in the primary care HIV clinic. Colocated interventions for chronic pain in this setting should not only focus on musculoskeletal pain but also account for complex multifaceted pain syndromes, and address the unique biopsychosocial features of this population. Furthermore, because chronic pain is prevalent in HIV and associated with increased healthcare utilization, developing clinic-based pain management programs could be cost-effective.
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http://dx.doi.org/10.1097/j.pain.0000000000000462DOI Listing
April 2016

A Mixed-Methods Pilot Study of Mindfulness-Based Stress Reduction for HIV-Associated Chronic Pain.

Behav Med 2017 Apr-Jun;43(2):108-119. Epub 2015 Dec 11.

a Department of Neurology , Icahn School of Medicine at Mount Sinai.

Treatment guidelines for chronic pain recommend nonpharmacologic modalities as part of a comprehensive management plan. Chronic pain is common among people living with HIV/AIDS, but there is little data to guide the choice of nonpharmacologic therapies in this complex population. We performed a mixed-methods feasibility study of Mindfulness-Based Stress Reduction (MBSR) versus health education control with 32 inner city, HIV-infected participants. Outcome measures included: the Brief Pain Inventory, Perceived Stress Scale, HIV Symptoms Index, autonomic function testing, and audiotaped focus groups. Post-intervention, participants reported modest improvements in pain measures and perceived stress, but no effect of group assignment was observed. At 3-month follow-up, 79% of MBSR participants were still practicing, and pain intensity was improved, whereas in the control group pain intensity had worsened. Qualitative analysis revealed a strong sense of community in both groups, but only MBSR was perceived as useful for relaxation and pain relief.
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http://dx.doi.org/10.1080/08964289.2015.1107525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005203PMC
March 2018

The Quantitative Analgesic Questionnaire: A Tool to Capture Patient-Reported Chronic Pain Medication Use.

J Pain Symptom Manage 2015 Sep 23;50(3):381-6. Epub 2015 Apr 23.

Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Context: The extent to which patients take chronic pain medications as prescribed is not well studied, and there are no generally agreed-upon measures. The Quantitative Analgesic Questionnaire (QAQ) is a new instrument designed to comprehensively document patient-reported medication use, generate scores to quantify it (by individual drug, class, and/or overall), and compare it (qualitatively and/or quantitatively) to the regimen as prescribed.

Objectives: The aim of this study was to describe the development and preliminary validation of the QAQ.

Methods: The QAQ was studied in a convenience sample of 149 HIV-infected participants.

Results: We found that the QAQ scores computed for participants' chronic pain medication regimens were valid based on their correlation with 1) patient-reported pain intensity (r = 0.38; P < 0.001) and 2) experienced pain management physicians' independent quantification of the regimens (r = 0.89; P < 0.001). The QAQ also demonstrated high interrater reliability (r = 0.957; P < 0.001). Detailed examination of the QAQ data in a subset of 34 participants demonstrated that the QAQ revealed suboptimal adherence in 44% of participants and contained information that would not have been gleaned from review of the medical record alone in 94%, including use of over-the-counter medications and quantification of "as needed" dosing. The QAQ also was found to be useful in quantifying change in the medication regimen over time, capturing a change in 50% of the participants from baseline to eight week follow-up.

Conclusion: The QAQ is a simple tool that can facilitate understanding of patient-reported chronic pain medication regimens, including calculation of percent adherence and generation of quantitative scores suitable for estimating and tracking change in medication use over time.
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http://dx.doi.org/10.1016/j.jpainsymman.2015.03.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4550505PMC
September 2015

Barriers to Chronic Pain Measurement: A Qualitative Study of Patient Perspectives.

Pain Med 2015 Jul 17;16(7):1256-64. Epub 2015 Feb 17.

Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objective: Preliminary evidence suggests that chronic pain patients complete pain intensity measures using idiosyncratic methods. Our objective was to understand these methods and how they might impact the psychometric properties of the instruments.

Design: A qualitative focus-group based study.

Setting: An academic center in New York City.

Subjects: Outpatients (n = 36) with chronic low back pain, or neuropathic pain due to diabetes or HIV.

Methods: Participants were divided into three focus groups based on their pain condition, and asked to discuss pain intensity measures (visual analog and numeric rating scales for average pain over 24 hours; Brief Pain Inventory; and McGill Pain Questionnaire). Audio-recordings were transcribed and analyzed using an inductive thematic method.

Results: We discovered four main themes, and five sub-themes: 1) doubt that pain can be accurately measured (subthemes: pain measurement is influenced by things other than pain, the numbers used to rate pain do not have an absolute meaning, and preference for pain intensity ratings "in the middle" of the scale); 2) confusion regarding the definition of pain; 3) what experiences to use as referents (subthemes: appropriate comparator experiences and the interpretation of the anchors of the scale); and 4) difficulty averaging pain.

Conclusions: The themes discovered suggest that patients include sensations and experiences other than pain intensity in their ratings, experience the rating of pain as a comparative task, and do not use the scale in a linear manner. These themes are relevant to understanding the validity and scale properties of commonly used pain intensity measures.
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http://dx.doi.org/10.1111/pme.12717DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504818PMC
July 2015

Predictors of new-onset distal neuropathic pain in HIV-infected individuals in the era of combination antiretroviral therapy.

Pain 2015 Apr;156(4):731-739

Children's Hospital, Los Angeles, CA, USA HIV Neurobehavioral Research Program, University of California, San Diego, CA, USA Icahn School of Medicine at Mount Sinai, New York, NY University of Washington, Seattle, WA, USA Washington University, St Louis, MO, USA University of Texas Medical Branch, Galveston, TX San Diego State University, San Diego, CA Alliant International University, San Diego, CA.

Despite modern combination antiretroviral therapy, distal neuropathic pain (DNP) continues to affect many individuals with HIV infection. We evaluated risk factors for new-onset DNP in the CNS Antiretroviral Therapy Effects Research (CHARTER) study, an observational cohort. Standardized, semiannual clinical evaluations were administered at 6 US sites. Distal neuropathic pain was defined by using a clinician-administered instrument standardized across sites. All participants analyzed were free of DNP at study entry. New-onset DNP was recorded at the first follow-up visit at which it was reported. Mixed-effects logistic regression was used to evaluate potential predictors including HIV disease and treatment factors, demographics, medical comorbidities, and neuropsychiatric factors. Among 493 participants, 131 (27%) reported new DNP over 2306 visits during a median follow-up of 24 months (interquartile range 12-42). In multivariable regression, after adjusting for other covariates, significant entry predictors of new DNP were older age, female sex, current and past antiretroviral treatment, lack of virologic suppression, and lifetime history of opioid use disorder. During follow-up, more severe depression symptoms conferred a significantly elevated risk. The associations with opioid use disorders and depression reinforce the view that the clinical expression of neuropathic pain with peripheral nerve disease is strongly influenced by neuropsychiatric factors. Delineating such risk factors might help target emerging preventive strategies, for example, to individuals with a history of opioid use disorder, or might lead to new treatment approaches such as the use of tools to ameliorate depressed mood.
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http://dx.doi.org/10.1097/01.j.pain.0000461252.75089.bfDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4374054PMC
April 2015

Optimizing measures of HIV-associated neuropathy.

Muscle Nerve 2015 Jan 21;51(1):56-64. Epub 2014 Nov 21.

Icahn School of Medicine at Mount Sinai, Department of Neurology, Box 1052, One Gustave L. Levy Place, New York, New York, 10029, USA.

Introduction: Distal symmetric polyneuropathy (DSP) is common in HIV and is associated with autonomic impairment. However tools to measure HIV-DSP do not include autonomic indices. We sought to optimize the Total Neuropathy Score (TNS) and the Composite Autonomic Severity Score (CASS) for use in HIV.

Methods: HIV-infected adults (n = 102) underwent neurologic examination, quantitative sensory testing (QST), nerve conduction studies, and autonomic testing. Modifications of the TNS and CASS were assessed for validity based on correlation with the original measure and internal consistency.

Results: The TNS version commonly used in HIV-DSP is valid, but it is improved by elimination of QST and addition of autonomic indices. A modified version of the CASS (M-CASS) which was designed for sensitivity to milder impairment was also valid.

Conclusions: A modified TNS that excludes QST and includes autonomic indices is optimal for HIV-DSP. The M-CASS is a valid measure of autonomic impairment in HIV.
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http://dx.doi.org/10.1002/mus.24282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4225193PMC
January 2015

HIV-associated distal neuropathic pain is associated with smaller total cerebral cortical gray matter.

J Neurovirol 2014 Jun 19;20(3):209-18. Epub 2014 Feb 19.

Department of Psychiatry, University of California San Diego, 220 Dickinson St., San Diego, CA, 92103, USA,

Despite modern antiretroviral therapy, HIV-associated sensory neuropathy affects over 50 % of HIV patients. The clinical expression of HIV neuropathy is highly variable: many individuals report few symptoms, but about half report distal neuropathic pain (DNP), making it one of the most prevalent, disabling, and treatment-resistant complications of HIV disease. The presence and intensity of pain is not fully explained by the degree of peripheral nerve damage, making it unclear why some patients do, and others do not, report pain. To better understand central nervous system contributions to HIV DNP, we performed a cross-sectional analysis of structural magnetic resonance imaging volumes in 241 HIV-infected participants from an observational multi-site cohort study at five US sites (CNS HIV Anti-Retroviral Treatment Effects Research Study, CHARTER). The association between DNP and the structural imaging outcomes was investigated using both linear and nonlinear (Gaussian Kernel support vector) multivariable regression, controlling for key demographic and clinical variables. Severity of DNP symptoms was correlated with smaller total cerebral cortical gray matter volume (r = -0.24; p = 0.004). Understanding the mechanisms for this association between smaller total cortical volumes and DNP may provide insight into HIV DNP chronicity and treatment-resistance.
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http://dx.doi.org/10.1007/s13365-014-0236-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4040150PMC
June 2014

Repurposing diflunisal for familial amyloid polyneuropathy: a randomized clinical trial.

JAMA 2013 Dec;310(24):2658-67

Departments of Medicine and Neurology, Mayo Clinic, Rochester, Minnesota.

Importance: Familial amyloid polyneuropathy, a lethal genetic disease caused by aggregation of variant transthyretin, induces progressive peripheral nerve deficits and disability. Diflunisal, a nonsteroidal anti-inflammatory agent, stabilizes transthyretin tetramers and prevents amyloid fibril formation in vitro.

Objective: To determine the effect of diflunisal on polyneuropathy progression in patients with familial amyloid polyneuropathy.

Design, Setting, And Participants: International randomized, double-blind, placebo-controlled study conducted among 130 patients with familial amyloid polyneuropathy exhibiting clinically detectable peripheral or autonomic neuropathy at amyloid centers in Sweden (Umeå), Italy (Pavia), Japan (Matsumoto and Kumamoto), England (London), and the United States (Boston, Massachusetts; New York, New York; and Rochester, Minnesota) from 2006 through 2012.

Intervention: Participants were randomly assigned to receive diflunisal, 250 mg (n=64), or placebo (n=66) twice daily for 2 years.

Main Outcomes And Measures: The primary end point, the difference in polyneuropathy progression between treatments, was measured by the Neuropathy Impairment Score plus 7 nerve tests (NIS+7) which ranges from 0 (no neurological deficits) to 270 points (no detectable peripheral nerve function). Secondary outcomes included a quality-of-life questionnaire (36-Item Short-Form Health Survey [SF-36]) and modified body mass index. Because of attrition, we used likelihood-based modeling and multiple imputation analysis of baseline to 2-year data.

Results: By multiple imputation, the NIS+7 score increased by 25.0 (95% CI, 18.4-31.6) points in the placebo group and by 8.7 (95% CI, 3.3-14.1) points in the diflunisal group, a difference of 16.3 points (95% CI, 8.1-24.5 points; P < .001). Mean SF-36 physical scores decreased by 4.9 (95% CI, -7.6 to -2.2) points in the placebo group and increased by 1.5 (95% CI, -0.8 to 3.7) points in the diflunisal group (P < .001). Mean SF-36 mental scores declined by 1.1 (95% CI, -4.3 to 2.0) points in the placebo group while increasing by 3.7 (95% CI, 1.0-6.4) points in the diflunisal group (P = .02). By responder analysis, 29.7% of the diflunisal group and 9.4% of the placebo group exhibited neurological stability at 2 years (<2-point increase in NIS+7 score; P = .007).

Conclusions And Relevance: Among patients with familial amyloid polyneuropathy, the use of diflunisal compared with placebo for 2 years reduced the rate of progression of neurological impairment and preserved quality of life. Although longer-term follow-up studies are needed, these findings suggest benefit of this treatment for familial amyloid polyneuropathy.

Trial Registration: clinicaltrials.gov Identifier: NCT00294671.
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http://dx.doi.org/10.1001/jama.2013.283815DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4139164PMC
December 2013

A Case of Reversible Neuropsychiatry Symptoms in HIV due to Toxic Leukoencephalopathy.

Innov Clin Neurosci 2013 Sep;10(9-10):26-9

Ms. Liu is from the Icahn School of Medicine at Mount Sinai, New York, New York; Dr. Garakani is from Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, and Silver Hill Hospital, New Canaan, Connecticut; Dr. Krauskopf is from Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; and Dr. Robinson-Papp is from Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York.

Mothball ingestion has been previously cited to induce toxic-leukoencephalopathy, secondary to the destructive effects of paradichlorobenzene on central nervous system white matter. This case presents a 37-year-old woman who experienced a neuropsychiatric syndrome consistent with paradichlorobenzene-induced toxic leukoencephalopathy after two decades of mothball abuse. Her clinical presentation was insidious, involving fluctuating cognitive decline, depression, and psychosis. This was further complicated by an human immunodeficiency virus infection and concomitant cocaine abuse. Ultimately, her clinical findings were attributed to a reversible toxic-leukoencephalopathy from mothball ingestion, and her magnetic resonance imaging findings were consistent with symmetric leukoencephalopathy and atrophy. Though leukoencephalopathy in human immunodeficiency virus has numerous potential etiologies, a patient with a history of substance abuse warrants consideration of toxin-induced leukoencephalopathy, and further inquiry regarding abuse of other substances is appropriate.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3849875PMC
September 2013

HIV-related neuropathy: current perspectives.

HIV AIDS (Auckl) 2013 Sep 11;5:243-51. Epub 2013 Sep 11.

Department of Neurology, Mount Sinai School of Medicine, New York, NY, USA.

Distal symmetric polyneuropathy (DSP) related to human immunodeficiency virus (HIV) is one of the most common neurologic complications of HIV, possibly affecting as many as 50% of all individuals infected with HIV. Two potentially neurotoxic mechanisms have been proposed to play a crucial role in the pathogenesis of HIV DSP: neurotoxicity resulting from the virus and its products; as well as adverse neurotoxic effects of medications used in the treatment of HIV. Clinically, HIV DSP is characterized by a combination of signs and symptoms that include decreased deep tendon reflexes at the ankles and decreased sensation in the distal extremities as well as paresthesias, dysesthesias, and pain in a symmetric stocking-glove distribution. These symptoms are generally static or slowly progressive over time, and depending on the severity, may interfere significantly with the patient's daily activities. In addition to the clinical picture, nerve conduction studies and skin biopsies are often pursued to support the diagnosis of HIV DSP. Anticonvulsants, antidepressants, topical agents, and nonspecific analgesics may help relieve neuropathic pain. Specifically, gabapentin, lamotrigine, pregabalin, amitriptyline, duloxetine, and high-dose topical capsaicin patches have been used in research and clinical practice. Further research is needed to elucidate the pathogenesis of HIV DSP, thus facilitating the development of novel treatment strategies. This review discusses the epidemiology, pathophysiology, clinical findings, diagnosis, and management of DSP in the setting of HIV.
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http://dx.doi.org/10.2147/HIV.S36674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775622PMC
September 2013

Autonomic neuropathy in HIV is unrecognized and associated with medical morbidity.

AIDS Patient Care STDS 2013 Oct 13;27(10):539-43. Epub 2013 Sep 13.

Department of Neurology, Ichan School of Medicine at Mount Sinai , New York, New York.

Autonomic dysfunction is common in HIV. However, its clinical impact is not well understood and its protean symptoms make it difficult to diagnose. We sought to determine: (1) whether autonomic neuropathy is associated with morbidity and predicted mortality in HIV as measured by the Veterans Aging Cohort Study (VACS) index; and (2) if healthcare providers recognize the diagnosis of autonomic neuropathy. Data were obtained from 102 HIV-infected adults enrolled in a prevalence study of autonomic dysfunction from 2011-2012. Participants were predominantly minority with nearly equal numbers of men and women. Most were receiving an antiretroviral regimen with a nucleoside reverse transcriptase inhibitor backbone and a base of a non-nucleoside reverse transcriptase inhibitor, protease inhibitor, or integrase inhibitor. Autonomic neuropathy was defined using a laboratory-based autonomic assessment, the Composite Autonomic Severity Score (CASS). Medical records were reviewed for the year prior to the autonomic assessment. We found that the autonomic neuropathy score (CASS) was associated with the VACS index. We also found that among 53 participants with symptomatic autonomic neuropathy, the diagnosis had been considered for only one. The majority of the symptoms were either unexplained or attributed to medication side effects. This study demonstrates that autonomic neuropathy in HIV is associated with serious co-morbid illnesses known to increase mortality risk, and that HIV healthcare providers rarely consider autonomic neuropathy in their differential diagnoses. Future studies are needed to determine if autonomic neuropathy is an independent risk factor for mortality in HIV, and to raise awareness of its signs and symptoms.
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http://dx.doi.org/10.1089/apc.2013.0188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3791048PMC
October 2013