Porque é impraticável para testar a fragilidade em todos os pacientes que frequentam uma clínica de HIV recomendamos os seguintes os pacientes sejam avaliados para a presença de fragilidade: os pacientes entrando cuidado com uma contagem de células CD4 &lt;200, pacientes com queixa de perda involuntária de peso, neuropatia grave ou pacientes que não são compatíveis com a terapia de HIV. <ol><li> Obter o consentimento verbal do paciente se submeter a testes de fragilidade ou de &quot;fraqueza&quot;. Consentimento não precisa ser escrito uma vez que tudo que é realizado faz parte de um exame físico normal. </li><li> Realizar um teste Mini-Cog, se o paciente parece confuso ou apático. <ol><li> Instrua o paciente a ouvir atentamente, e lembre-se três palavras não relacionadas. O examinador estados as três palavras em voz alta. </li><li> Instrua o paciente para desenhar o rosto de um relógio, ou em uma folha de papel em branco ou numa folha com o círculo relógio já desenhado na página. Depois que o paciente coloca os números na face do relógio, pergunte a ele ou her para desenhar os ponteiros do relógio para ler um tempo específico. </li><li> Peça ao paciente para repetir as três palavras previamente estabelecidas. Dê um ponto para cada palavra lembrada. Pacientes lembrando nenhuma das três palavras são classificados como prejudicados cognitivamente (escore = 0). Pacientes que lembram as três palavras são classificados como pacientes cognitivamente intactas (Score = 3) com a palavra intermediária recall de 1-2 palavras são classificados com base no teste de empate relógio (anormal = prejudicada; Normal = intacto). </li><li> Se o paciente não o Mini-Cog, o médico deve examinar melhor as causas de confusão e / ou delírio. Teste de fragilidade não seria apropriado neste momento. </li></ol></li><li> Pesar paciente e avaliar a perda de peso. Alguém que é frágil pode ter perda de peso não intencional de ≥ 10 quilos em relação ao ano anterior. </li><li> Tempo pé de um paciente para a lentidão. Alguém que é frágil, tem um tempo de caminhada diminuiu conforme definido por um teste de caminhada de 15 metros cronometrados. O tempo é ajustada para sexo e standialtura ng. Homens com uma altura de &lt;173 centímetros e mulheres com uma altura &lt;159 centímetros que andaram 15 pés em&gt; 7 segundos são considerados frágeis, os homens&gt; 173 centímetros e mulheres&gt; 159 centímetros que andaram 15 pés em&gt; 6 segundos são considerados frágeis. </li><li> Determinar se o paciente tem fraqueza. Fraqueza é estabelecida quando há uma redução na força de preensão medida por um dinamômetro com o valor ajustado para sexo e índice de massa corporal (IMC). Os homens com um IMC &lt;24 são considerados frágeis, se a força de preensão (kg) é &lt;29, para um IMC de 24,1-28, o homem é frágil, se &lt;30, para um IMC&gt; 28 um homem é frágil, se &lt;32. Para as mulheres, um IMC &lt;23 é considerada frágil, se a força de preensão (kg) é &lt;17, um IMC 23,1-26 é considerado frágil se &lt;17.3, um IMC de 26,1-29 é considerado frágil, se &lt;18 anos, e um IMC &gt; 29 é considerado frágil, se &lt;21. </li><li> Determinar se o paciente tem um baixo nível de atividade física. Este é estabelecido por uma pontuação ponderada de quilocalorias gastas por semana medido pelo Minnesota Leisure Time Activity Questionnaire. O questionário pergunta sobre as atividades da vida diária, como esportes e hobbies. Fragilidade está presente quando os machos usam &lt;383kcal/week, e as fêmeas &lt;270 kcal / semana. 12 </li><li> Determinar se o paciente mostra evidências de exaustão. Esta é a auto-relatado por responder duas perguntas do Centro de Estudos Epidemiológicos Depression Scale 13 As perguntas são: Quantas vezes na última semana você sentiu: (a) de que tudo que fiz foi um esforço, ou (b).? Eu não poderia ir embora? As respostas foram: 0 = menos de 1 dia, 1 = 1-2 dias, 3-4 dias, 2 =, 3 = a maior parte do tempo. Respondendo a 2 ou 3 para qualquer uma destas perguntas é um critério positivo para a fragilidade 14. </li></ol>

<ol>
	<li>Ianas, V., Berg, E., Mohler, M. J., Wendel, C., Klotz, S. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Antiretroviral+therapy+protects+against+frailty+in+HIV-1+infection.">Antiretroviral therapy protects against frailty in HIV-1 infection.</a> J. Int. Assoc. Physicians AIDS Care. , (2012).</li><li>Fried, L. P., Tangen, C. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+in+older+adults:+evidence+for+a+phenotype.">Frailty in older adults: evidence for a phenotype.</a> J. Gerontol. A. Biol. Sci. Med. Sci. 56 (3), M146-M156 (2001).</li><li>Effros, R. B., Fletcher, C. V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aging+and+infectious+diseases:+workshop+on+HIV+infection+and+aging:+what+is+known+and+future+research+directions.">Aging and infectious diseases: workshop on HIV infection and aging: what is known and future research directions.</a> Clin. Infect. Dis. 47 (4), 542-553 (2008).</li><li>Desquilbet, L., Jacobson, L. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=HIV-1+infection+is+associated+with+an+earlier+occurrence+of+a+phenotype+related+to+frailty.">HIV-1 infection is associated with an earlier occurrence of a phenotype related to frailty.</a> J. Gerontol. A. Biol. Sci. Med. Sci. 62 (11), 1279-1286 (2007).</li><li>Desquilbet, L., Margolick, J. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Relationship+between+a+frailty-related+phenotype+and+progressive+deterioration+of+the+immune+system+in+HIV-infected+men.">Relationship between a frailty-related phenotype and progressive deterioration of the immune system in HIV-infected men.</a> J. Acquir. Immune Defic. Syndr. 50 (3), 299-306 (2009).</li><li>Onen, N. F., Agbebi, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+among+HIV-infected+persons+in+an+urban+outpatient+care+setting.">Frailty among HIV-infected persons in an urban outpatient care setting.</a> J. Infect. 59 (5), 346-352 (2009).</li><li>Terzian, A. S., Holman, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Factors+associated+with+preclinical+disability+and+frailty+among+HIV-infected+and+HIV-uninfected+women+in+the+era+of+cART.">Factors associated with preclinical disability and frailty among HIV-infected and HIV-uninfected women in the era of cART.</a> J. Womens Health (Larchmt). 18 (12), 1965-1974 (2009).</li><li>Ahmed, N., Mandel, R., Fain, M. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty:+an+emerging+geriatric+syndrome.">Frailty: an emerging geriatric syndrome.</a> Am. J. Med. 120 (9), 748-753 (2007).</li><li>Bergman, H., Ferrucci, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty:+an+emerging+research+and+clinical+paradigm--issues+and+controversies.">Frailty: an emerging research and clinical paradigm--issues and controversies.</a> J. Gerontol. A. Biol. Sci. Med. Sci. 62 (7), 731-737 (2007).</li><li>Bandeen-Roche, K., Xue, Q. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Phenotype+of+frailty:+characterization+in+the+women's+health+and+aging+studies.">Phenotype of frailty: characterization in the women's health and aging studies.</a> J. Gerontol. A. Biol. Sci. Med. Sci. 61 (3), 262-266 (2006).</li><li>Wilson, J. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty--and+its+dangerous+effects--might+be+preventable.">Frailty--and its dangerous effects--might be preventable.</a> Ann. Intern. Med. 141 (6), 489-492 (2004).</li><li>Martin, C. P., Fain, M. J., Klotz, S. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+older+HIV-positive+adult:+a+critical+review+of+the+medical+literature.">The older HIV-positive adult: a critical review of the medical literature.</a> Am. J. Med. 121 (12), 1032-1037 (2008).</li><li>Taylor, H. L., Jacobs, D. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+questionnaire+for+the+assessment+of+leisure+time+physical+activities.">A questionnaire for the assessment of leisure time physical activities.</a> J. Chronic Dis. 31 (12), 741-755 (1978).</li><li>Radloff, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+CES-D+Scale:+A+self-report+depression+scale+for+research+in+the+general+population.">The CES-D Scale: A self-report depression scale for research in the general population.</a> Applied Psychological Measurement. 1 (3), 385-401 (1977).</li></ol>

No conflicts of interest declared.

Previous studies of HIV and frailty: Two retrospective studies by Desquilbet et al. assessed frailty in a cohort of men who have sex with men from the Multicenter AIDS Cohort Studies (MACS). Both studies used a shortened definition of frailty containing fewer criteria than did our study. The first study compared frailty in HIV-1 infected men in the pre-treatment era to a control group of HIV uninfected men.4 There were similar rates of frailty in HIV+ men older than 55 years and HIV- men older than 65 years; frailty was found to occur earlier in HIV-1 infected men. Our study had similar findings of an earlier occurrence of frailty phenotype, but we obtained higher rates of frailty compared with MACS, possibly because our use of the full Fried frailty criteria versus surrogate administrative data, but also because of the different population of patients in our study.
Another study by Desquilbet et al. evaluated CD4 cell count and HIV viral load as predictors of frailty in HIV+ men and found that lower CD4 cell counts and viral loads of more than 50,000 copies of RNA were significantly associated with frailty.5 Also the prevalence of frailty declined in the era of ART. Despite differences in measuring frailty and in population characteristics our study concluded like Desquilbet et al. that a low CD4 cell count is significantly associated with frailty and that patients on long-term ART have less likelihood of developing frailty.1 Premature occurrence of prevalence of frailty, shorter duration of ART, more co-morbidities and lower CD4 count were associated with frailty in both studies, but we did not find a strong association between psychiatric diagnosis and frailty. We found a positive relationship between length of ART and not being frail (Figure 1).
Our findings of frailty in HIV patients: Our initial hypothesis that age was not significantly important when measuring frailty of patients with low CD4 cell counts was confirmed. Frailty is likely more causally related to the inflammatory state and profound immunosuppression found in many patients with low CD4 cell counts. Many of these patients had a history of recently treated opportunistic infections. Because of these observations we propose that an active diagnosis of AIDS (CD4 cell count &lt;200 cells/&mu;l) is a significant co-morbidity itself and significantly predisposes patients to being frail. All of our frail patients had at least one co-morbidity besides HIV itself. Our frail patients &lt;50 years had significantly fewer co-morbidities than the frail population &gt;50 years, though in comparison, the younger people had a lower CD4 cell count.
Our other hypothesis was that frailty may be temporary in younger patients with low CD4 cell counts and may revert when CD4 cell counts improve. We were limited by the low number of patients and this hypothesis could not be proven, but it was a likelyexplanation for the small number of patients in which reversal was demonstrated (Table 1). Longer antiretroviral treatment was found to be protective for frailty (Figure 1). This fact on its own would support the recommendations of starting ART at higher CD4 counts and continuing ART without any treatment breaks. We believe that the main reason by which length of ART treatment was shown to be protective for frailty is that patients on long term treatment are more likely to have better control of co-morbidities as well as HIV and less likely to be frail.
In conclusion we have observed an association between low CD4-cell counts and frailty, which is not affected by age, viral load or the presence of co-morbidities. Effective treatment with ART plays a protective role against frailty, reinforcing the importance of effective ART. Early implementation of ART in the care of HIV patients may protect against frailty. Though not tested in our study, future research should address other interventions known to reverse frailty in the aged including treating deconditioning, protein-energy malnutrition, depression, and vitamin D deficiency.

Os Centros de Controle de Doenças projetos que mais da metade dos HIV-1 indivíduos infectados nos Estados Unidos estarão ao longo do 50 anos de idade até o ano de 2015. O aumento da expectativa de vida de um HIV-infectados vida resultou em um aumento inesperado na co-morbidades relacionadas ao envelhecimento, colocando anciãos HIV-positivos no aumento do risco de morbidade e mortalidade. Um exemplo importante disto é com a síndrome de recém-descrita de fragilidade, o que pode jogar um papel importante no envelhecimento acelerado do VIH-1 adultos infectados 3-7. A fragilidade foi definido na idade biológica como uma síndrome de diminuição da reserva e resistência a factores de stress, resultante do declínio cumulativo dos sistemas fisiológicos e progride frequentemente numa diminuição funcional gradual ao longo do tempo. A importância clinica de fragilidade é que o síndroma é considerado um estado de alto risco, preditivo de efeitos adversos à saúde, tais como diminuição da função e mobilidade, hospitalizatíons e morte. 8 Numerosos estudos nos últimos 10 anos têm tentado avaliar a fragilidade em diferentes populações. Fried et al. Estudaram fragilidade em homens e mulheres com mais de 65 anos de idade, matriculadas em um estudo cardiovascular. 2 A definição de fragilidade foi validado em um estudo realizado com mulheres de envelhecimento. 9 Modificações de sua definição tem sido utilizado em outros estudos, incluindo HIV-1 indivíduos infectados. 4-7 Fried et al. descrito um fenótipo frágil que, mesmo na ausência de deficiência ou co-morbidades mostrou que 7% da população com mais de 65 anos de idade, ao passo que são frágeis, com mais de 20-26% 80 anos de idade eram frágeis. Frailty 2 pode ser um dado primário, mas também um diagnóstico secundário, como resultado de um evento agudo ou como co-morbilidade malignidade, aterosclerose, infecção (HIV), ou a depressão. 10 Além disso, outros factores susceptíveis contribuir para a fragilidade em pacientes com HIV, por exemplo, o abuso de drogas intravenosas,indigência e doença mental. Fragilidade foi encontrado em HIV-1 infectados em idades mais jovens do que os pacientes não infectados pelo VIH. 4 Mais HIV-1 indivíduos infectados freqüentemente apresentam doença mais grave HIV e têm um tempo de sobrevivência menor do que os indivíduos mais jovens, muitas vezes, porque eles não são diagnosticados até muito tarde no processo da doença 11. Outra razão pode ser que os pacientes mais velhos têm mais doenças co-mórbidas interagindo com HIV-1. Idosos do HIV-1 indivíduos infectados foram descritos como mais frágil do que os indivíduos de controlo de idade correspondente sem infecção pelo HIV-1 4. Medição clínica de fragilidade em pacientes infectados pelo HIV-1 é importante, pois a fragilidade pode ser reversível em seus estágios iniciais (por exemplo, intervenções para reverter o descondicionamento, desnutrição protéico-energética, depressão, deficiência de vitamina D e outras condições relacionadas com a fragilidade) antes de reservas exauridas chegar a um crítico limiar levando avulnerabilidade e irreversível declínio funcional.

measuring frailty in hiv-infected individuals. identification of frail patients is the first step to amelioration and reversal of frailty

Um protocolo simples, validado consiste de uma bateria de testes está disponível para identificar pacientes idosos com síndrome de fragilidade. Esta síndrome de diminuição da reserva e resistência ao estresse aumenta da incidência com o aumento da idade. Nos idosos, a fraqueza pode exercer uma perda gradual da função do não-frágeis para pré-frágeis para frágil. Estudámos fragilidade em pacientes infectados pelo HIV e descobriu que ~ 20% são frágeis usando o fenótipo fritada utilizando critérios rigorosos desenvolvidos para idosos 1,2. Na infecção por HIV a síndrome ocorre em uma idade mais jovem. Pacientes com HIV foram verificados por 1) a perda de peso não intencional, 2), conforme determinado pelo lentidão velocidade de marcha, 3) fraqueza como medida por um dinamómetro de aperto, 4) exaustão pelas respostas a uma escala de depressão e 5) acessível a actividade física foi determinada pela avaliação quilocalorias consumidas em uma semana. Pré-fragilidade esteve presente com dois dos cinco critérios e fragilidade estava presente se houver trêsos cinco critérios eram anormais. Os testes levam cerca de 10-15 minutos para ser concluído e que pode ser realizado por médicos assistentes durante as visitas clínicas de rotina. Os resultados dos testes são marcados por referência às tabelas padrão. Entendendo que um dos cinco componentes contribuem para a fragilidade em um paciente individual pode permitir que o clínico para resolver os problemas subjacentes relevantes, muitas das quais não são evidentes em visitas à clínica de rotina de HIV.

One hundred outpatient HIV-1-infected persons were prospectively tested for clinical markers of frailty to include shrinking weight, slowness in walking, decrease in grip strength, low activity, and exhaustion. Eighty-one patients were not frail when studied, 19 patients were frail at the initial assessment (Table 1). The characteristics of the frail and non-frail patients were not significantly different except for a higher rate of hepatitis C and neuropathy in the frail group (p &lt; 0.05). Length of infection with HIV, CD4 count and HIV-1 RNA viral load were also compared. As shown in Table 2 the younger patients had a greater incidence of frailty and this was associated with low CD4 cell counts. CD4 counts &lt;200 cells/mm3 were associated with 9-fold increased odds of frailty relative to patients with a CD4 count &gt;350 cells/mm3 (odds ratio [OR] 9.0, 95% confidence interval [CI] 2.1-44). Seven frail patients were measured 6 months later: 2 died refusing therapy, 4 were no longer frail, and 1 patient remained frail (Table 3). From this data it appears that when patients took prescribed anti-retroviral therapy the CD4 cell counts improved along with an improvement in the general state of health of the patient. Finally, if the incidence of frailty in the study population is compared to the number of years of anti-retroviral therapy taken by the patients, the longer patients took anti-retroviral therapy, the less the incidence of frailty (p &lt; 0.05). This fact supports the early use of anti-retroviral therapy in HIV-infected patients which is the preferred approach in recent HIV treatment guidelines.15
We conclude that frailty is common in HIV outpatients and is associated with low CD4 counts more than with advancing age. Our data suggest that frailty is transient, especially in younger patients who may revert to their prefrail state unlike uninfected elderly individuals in whom a stepwise decline in function may occur.
Representative Results from our Previous Study1
<table border="1">
	<tbody>
		<tr>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
			<td>Frail, N=19 (19%)</td>
			<td>Non-Frail, N=81 (81%)</td>
		</tr>
		<tr>
			<td>Sex</td>
			<td>Male</td>
			<td>14 (74%)</td>
			<td>60 (74%)</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td>Female</td>
			<td>5 (26%)</td>
			<td>21 (26%)</td>
		</tr>
		<tr>
			<td>Age</td>
			<td>&lt;50</td>
			<td>12 (63%)</td>
			<td>46 (57%)</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td>&gt;=50</td>
			<td>7 (37%)</td>
			<td>35 (43%)</td>
		</tr>
		<tr>
			<td>Comorbidity</td>
			<td>Dyslipidemia</td>
			<td>6 (32%)</td>
			<td>25 (31%)</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td>Psychiatric</td>
			<td>4 (21%)</td>
			<td>29 (36%)</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td>Neuropathy</td>
			<td>8 (42%)</td>
			<td>15 (19%)</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td>Hypertension</td>
			<td>2 (11%)</td>
			<td>17 (21%)</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td>Hepatitis C</td>
			<td>6 (32%)</td>
			<td>12 (15%)</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td>Diabetes mellitus</td>
			<td>3 (16%)</td>
			<td>6 (7%)</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td>Coronary artery disease</td>
			<td>1 (1%)</td>
			<td>5 (6%)</td>
		</tr>
	</tbody>
</table>
Table 1. Clinical characteristics of the HIV study patients. Frail patients were compared to non-frail HIV patients with respect to sex, age and comorbidities. The presence of neuropathy and infection with hepatitis C were significant differences between the frail and non-frail patients.
<table border="1">
	<tbody>
		<tr>
			<td>CD4 Cell Count (cells/&mu;l)</td>
			<td>&lt;50 Years of Age, N (%)</td>
			<td>&gt;=50 Years of Age, N (%)</td>
		</tr>
		<tr>
			<td>&lt;200</td>
			<td>7</td>
			<td>3</td>
		</tr>
		<tr>
			<td>200-350</td>
			<td>4</td>
			<td>1</td>
		</tr>
		<tr>
			<td>&gt;350</td>
			<td>1</td>
			<td>3</td>
		</tr>
		<tr>
			<td>&Rho;-value</td>
			<td>0.028</td>
			<td>0.021</td>
		</tr>
	</tbody>
</table>
Table 2. Frail patients and the relationship of age and CD4 cell count in these patients. The frail patients were significantly younger and with lower CD4 cell counts than non-frail patients.
<table border="1">
	<tbody>
		<tr>
			<td>Patient</td>
			<td>Initial CD4 Cell Count (cells/&mu;l)</td>
			<td>Initial Viral Load (RNA copies/&mu;l)</td>
			<td>Retest CD4 Cell Count (cells/&mu;l)</td>
			<td>Retest Viral Load (RNA copies/&mu;l)</td>
			<td>Comorbidity</td>
			<td>Outcome</td>
		</tr>
		<tr>
			<td>1</td>
			<td>26</td>
			<td>2 million</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>hepatitis C, alcoholism</td>
			<td>Dead; refused ART</td>
		</tr>
		<tr>
			<td>2</td>
			<td>3</td>
			<td>52,000</td>
			<td>1</td>
			<td>82,000</td>
			<td>coccidioido-mycosis</td>
			<td>Dead; stopped ART</td>
		</tr>
		<tr>
			<td>3</td>
			<td>12</td>
			<td>12,000</td>
			<td>36</td>
			<td>&lt;48</td>
			<td>none</td>
			<td>Not frail</td>
		</tr>
		<tr>
			<td>4</td>
			<td>169</td>
			<td>&lt;48</td>
			<td>991</td>
			<td>&lt;48</td>
			<td>blindness, peripheral neuropathy, pulmonary embolism</td>
			<td>Not frail</td>
		</tr>
		<tr>
			<td>5</td>
			<td>141</td>
			<td>1,000</td>
			<td>54</td>
			<td>&lt;48</td>
			<td>lymphoma, peripheral neuropathy</td>
			<td>Not frail</td>
		</tr>
		<tr>
			<td>6</td>
			<td>151</td>
			<td>&lt;48</td>
			<td>393</td>
			<td>&lt;48</td>
			<td>coccidioido-mycosis, deep venous thrombosis</td>
			<td>Not frail</td>
		</tr>
		<tr>
			<td>7</td>
			<td>106</td>
			<td>44,620</td>
			<td>229</td>
			<td>&lt;48</td>
			<td>hepatitis C, chronic obstructive lung disease</td>
			<td>Frail</td>
		</tr>
	</tbody>
</table>
Table 3. Outcomes of 7 frail patients with low CD4 cell counts. These patients all needed anti-retroviral therapy, were prescribed therapy and then retested for frailty 6 months later. Only one patient who took the prescribed anti-retroviral therapy was still frail 6 months later.
<img alt="Figure 1" src="/files/ftp_upload/50537/50537fig1.jpg" /> 
 Figure 1. Relationship between number of years of taking anti-retroviral therapy and the incidence of frailty (89 patients were taking anti-retroviral therapy). The longer patients took anti-retroviral therapy the less the incidence of frailty in that population (p &lt; 0.05).

Watch this Scientific Journal Video about Measuring Frailty in HIV-infected Individuals. Identification of Frail Patients is the First Step to Amelioration and Reversal of Frailty at JoVE.com

Measuring Frailty in HIV-infected Individuals. Identification of Frail Patients is the First Step to Amelioration and Reversal of Frailty

Frailty syndrome is commonly seen in the aged and reflects multi-system physiological change. However, with reduced functional reserve and resilience frailty is also known to be common in the HIV infected population. This study outlined an easily administered screening test to identify HIV patients with frailty. When significant components of frailty are identified, clinicians will be able to focus on amelioration of the problem and promote reversion to the pre-frail state.

Medindo fragilidade em indivíduos infectados pelo HIV. Identificação de pacientes frágeis é o primeiro passo para a Melhoria e Reversão de fragilidade

A simple, validated protocol consisting of a battery of tests is available to identify elderly patients with frailty syndrome. This syndrome of decreased ...

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Medicine

16.1K visualizações.  University of Arizona. Frailty syndrome is commonly seen in the aged and reflects multi-system physiological change. However, with reduced functional reserve and resilience frailty is also known to be common in the HIV infected population. This study outlined an easily administered screening test to identify HIV patients with frailty. When significant components of frailty are identified, clinicians will be able to focus on amelioration of the problem and promote reversion to the pre-frail stat...

Vídeo: Measuring Frailty in HIV-infected Individuals. Identification of Frail Patients is the First Step to Amelioration and Reversal of Frailty

Manual Muscle Testing:  A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients

Survivors of acute respiratory distress syndrome (ARDS) and other causes of critical illness often have generalized weakness, reduced exercise tolerance, and persistent nerve and muscle impairments after hospital discharge.1-6 Using an explicit protocol with a structured approach to training and quality assurance of research staff, manual muscle testing (MMT) is a highly reliable method for assessing strength, using a standardized clinical examination, for patients following ARDS, and can be completed with mechanically ventilated patients who can tolerate sitting upright in bed and are able to follow two-step commands. 7, 8 
This video demonstrates a protocol for MMT, which has been taught to &ge;43 research staff who have performed &gt;800 assessments on &gt;280 ARDS survivors. Modifications for the bedridden patient are included. Each muscle is tested with specific techniques for positioning, stabilization, resistance, and palpation for each score of the 6-point ordinal Medical Research Council scale.7,9-11 Three upper and three lower extremity muscles are graded in this protocol: shoulder abduction, elbow flexion, wrist extension, hip flexion, knee extension, and ankle dorsiflexion. These muscles were chosen based on the standard approach for evaluating patients for ICU-acquired weakness used in prior publications. 1,2.

Survivors of acute respiratory distress syndrome (ARDS) and critical illness frequently develop long-lasting muscle weakness. Manual muscle testing (MMT) is a standardized clinical examination commonly used to measure strength of peripheral skeletal muscle groups. This video demonstrates MMT using the 6-point Medical Research Council scale.

Teste muscular manual: um método de medir a força muscular Extremidade Aplicada à pacientes criticamente enfermos

Survivors of acute respiratory distress syndrome (ARDS) and other causes of critical illness often have generalized weakness, reduced exercise tolerance, ...

Medicina

Sequencing of Bacterial Microflora in Peripheral Blood: our Experience with HIV-infected Patients

The healthy gastrointestinal tract is physiologically colonized by a large variety of commensal microbes that influence the development 
	of the humoral and cellular mucosal immune system1,2. 
 Microbiota is shielded from the immune system via a strong mucosal barrier. Infections and antibiotics are known to alter both the normal 
	gastrointestinal tract barrier and the composition of resident bacteria, which may result in possible immune abnormalities3.
HIV causes a breach in the gastrointestinal barrier with progressive failure of mucosal immunity and leakage into the systemic circulation of bacterial bioproducts, such as lipopolysaccharide and 
	bacterial DNA fragments, which contribute to systemic immune activation4-7. Microbial translocation is implicated in HIV/AIDS immunopathogenesis and response to therapy 4,8.
We aimed to characterise the composition of bacteria translocating in peripheral blood of HIV-infected patients. To pursue our aim we set up a PCR reaction for the panbacteric 16S ribosomial gene 
	followed by a sequencing analysis.
Briefly, whole blood from both HIV-infected and healthy subjects is used. Given that healthy individuals present normal intestinal homeostasis no translocation of microflora is expected in 
	these patients. Following whole blood collection by venipuncture and plasma separation, DNA is extracted from plasma and used to perform a broad range PCR reaction for the panbacteric 
	16S ribosomial gene9. Following PCR product purification, cloning and sequencing analyses are performed.

Our experiment will show how to perform a sequencing analysis of bacterial species translocating in peripheral blood of HIV positive patients.

Seqüenciamento da microflora bacteriana no sangue periférico: a nossa experiência com pacientes infectados pelo HIV

The healthy gastrointestinal tract is physiologically colonized by a large variety of commensal microbes that influence the development 
	of the humoral ...

The Measurement and Treatment of Suppression in Amblyopia

Amblyopia, a developmental disorder of the visual cortex, is one of the leading causes of visual dysfunction in the working age population. Current estimates put the prevalence of amblyopia at approximately 1-3%1-3, the majority of cases being monocular2. Amblyopia is most frequently caused by ocular misalignment (strabismus), blur induced by unequal refractive error (anisometropia), and in some cases by form deprivation.
Although amblyopia is initially caused by abnormal visual input in infancy, once established, the visual deficit often remains when normal visual input has been restored using surgery and/or refractive correction. This is because amblyopia is the result of abnormal visual cortex development rather than a problem with the amblyopic eye itself4,5 . Amblyopia is characterized by both monocular and binocular deficits6,7 which include impaired visual acuity and poor or absent stereopsis respectively. The visual dysfunction in amblyopia is often associated with a strong suppression of the inputs from the amblyopic eye under binocular viewing conditions8. Recent work has indicated that suppression may play a central role in both the monocular and binocular deficits associated with amblyopia9,10 .
Current clinical tests for suppression tend to verify the presence or absence of suppression rather than giving a quantitative measurement of the degree of suppression. Here we describe a technique for measuring amblyopic suppression with a compact, portable device11,12 . The device consists of a laptop computer connected to a pair of virtual reality goggles. The novelty of the technique lies in the way we present visual stimuli to measure suppression. Stimuli are shown to the amblyopic eye at high contrast while the contrast of the stimuli shown to the non-amblyopic eye are varied. Patients perform a simple signal/noise task that allows for a precise measurement of the strength of excitatory binocular interactions. The contrast offset at which neither eye has a performance advantage is a measure of the "balance point" and is a direct measure of suppression. This technique has been validated psychophysically both in control13,14 and patient6,9,11 populations.
In addition to measuring suppression this technique also forms the basis of a novel form of treatment to decrease suppression over time and improve binocular and often monocular function in adult patients with amblyopia12,15,16 . This new treatment approach can be deployed either on the goggle system described above or on a specially modified iPod touch device15.

Amblyopia is a developmental disorder of the visual cortex that is often accompanied by strong suppression of one eye. We present a new technique for measuring and treating interocular suppression in patients with amblyopia that can be deployed using virtual reality goggles or a portable iPod Touch device.

A Medição e Tratamento de Supressão de ambliopia

Amblyopia, a developmental disorder of the visual cortex, is one of the leading causes of visual dysfunction in the working age population. Current ...

Collecting Saliva and Measuring Salivary Cortisol and Alpha-amylase in Frail Community Residing Older Adults via Family Caregivers

Salivary measures have emerged in bio-behavioral research that are easy-to-collect, minimally invasive, and relatively inexpensive biologic markers of stress. This article we present the steps for collection and analysis of two salivary assays in research with frail, community residing older adults-salivary cortisol and salivary alpha amylase. The field of salivary bioscience is rapidly advancing and the purpose of this presentation is to provide an update on the developments for investigators interested in integrating these measures into research on aging. Strategies are presented for instructing family caregivers in collecting saliva in the home, and for conducting laboratory analyses of salivary analytes that have demonstrated feasibility, high compliance, and yield quality specimens. The protocol for sample collection includes: (1) consistent use of collection materials; (2) standardized methods that promote adherence and minimize subject burden; and (3) procedures for controlling certain confounding agents. We also provide strategies for laboratory analyses include: (1) saliva handling and processing; (2) salivary cortisol and salivary alpha amylase assay procedures; and (3) analytic considerations.

We demonstrate: (1) procedures for collection of salivary samples in cognitive impaired older adults by family caregivers in the home setting, (2) procedures for measuring stress activity via salivary cortisol and alpha amylase, and (3) representative profiles. Protocols that allow researchers to study stress-linked processes advance our understanding of biological sensitivity and susceptibility.

Salivary measures have emerged in bio-behavioral research  that are easy-to-collect, minimally invasive, and relatively inexpensive  biologic markers of ...

Heterotopic Renal Autotransplantation in a Porcine Model: A Step-by-Step Protocol

Kidney transplantation is the treatment of choice for patients suffering from end-stage renal disease. It offers better life expectancy and higher quality of life when compared to dialysis. Although the last few decades have seen major improvements in patient outcomes following kidney transplantation, the increasing shortage of available organs represents a severe problem worldwide. To expand the donor pool, marginal kidney grafts recovered from extended criteria donors (ECD) or donated after circulatory death (DCD) are now accepted for transplantation. To further improve the postoperative outcome of these marginal grafts, research must focus on new therapeutic approaches such as alternative preservation techniques, immunomodulation, gene transfer, and stem cell administration.
Experimental studies in animal models are the final step before newly developed techniques can be translated into clinical practice. Porcine kidney transplantation is an excellent model of human transplantation and allows investigation of novel approaches. The major advantage of the porcine model is its anatomical and physiological similarity to the human body, which facilitates the rapid translation of new findings to clinical trials. This article offers a surgical step-by-step protocol for an autotransplantation model and highlights key factors to ensure experimental success. Adequate pre- and postoperative housing, attentive anesthesia, and consistent surgical techniques result in favorable postoperative outcomes. Resection of the contralateral native kidney provides the opportunity to assess post-transplant graft function. The placement of venous and urinary catheters and the use of metabolic cages allow further detailed evaluation. For long-term follow-up studies and investigation of alternative graft preservation techniques, autotransplantation models are superior to allotransplantation models, as they avoid the confounding bias posed by rejection and immunosuppressive medication.

Porcine models of organ transplantation provide an important platform to study mechanisms of organ preservation. This article describes a heterotopic porcine renal autotransplantation model, which allows investigating new approaches to improve the outcome of transplantation using marginal kidney grafts.

Heterotópico Renal autotransplante em um modelo suíno: Um Protocolo Passo-a-Passo

Kidney transplantation is the treatment of choice for patients suffering from end-stage renal disease. It offers better life expectancy and higher quality ...

Exergaming in Older People Living with HIV Improves Balance, Mobility and Ameliorates Some Aspects of Frailty

Approximately 1.2 million people in the United States live with HIV infection. Medical advancements have increased the life expectancy and this cohort is aging. HIV-positive individuals have a high incidence of frailty (~20%) characterized by depression and sedentary behavior. Exercise would be healthy, but due to the frail status of many HIV-positive individuals, conventional exercise is too taxing. The aim of this study was to evaluate the effectiveness and acceptability of a novel game-based training program (exergame) in ameliorating some aspects of frailty in HIV-infected individuals. Ten older people living with HIV were enrolled in an exergame intervention. Patients performed balance exercises such as weight shifting, ankle reaching, and obstacle crossing. Real-time visual/audio lower-extremity joint motion feedback was provided using wearable sensors to assist feedback and encourage subjects to accurately execute each exercise task. Patients trained twice a week for 45 min for 6 weeks. Changes in balance, gait, psychosocial parameters and quality of life parameters were assessed at the beginning, midterm and at conclusion of the training program. Ten patients completed the study and their results analyzed. The mean age was 57.2 &#177; 9.2 years. The participants showed a significant reduction in center of mass sway (78.2%, p = .045) during the semi-tandem balance stance with eyes closed and showed a significant increase in gait speed during a dual task motor-cognitive assessment (9.3%, p = .048) with an increase in stride velocity of over 0.1 m/sec. A significant reduction in reported pain occurred (43.5%, p = .041). Preliminary results of this exergame intervention show promise in improving balance and mobility while requiring older people living with HIV to be more active. The exergame can be continued at home and may have long term as well as short-term benefits for ameliorating frailty associated with HIV infection.

Persons infected with HIV are often frail, depressed and live a sedentary lifestyle for which conventional exercise is too taxing. Here, we present an exercise protocol that ameliorates aspects of frailty in HIV-infected persons. An exergame integrating cognitive control was developed using biosensors that measured balance, weight-shifting and obstacle crossing.

Exergaming em pessoas idosas que vivem com HIV melhora o equilíbrio, mobilidade e melhora alguns aspectos da fragilidade

Approximately 1.2 million people in the United States live with HIV infection. Medical advancements have increased the life expectancy and this cohort is ...

Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs easily when performing another operation for laparoscopic common bile duct exploration (LCBDE), which was once considered a relative contraindication. In view of the limitations of the current surgical technique, this study summarized the surgical approaches and crucial anatomical landmarks for reoperation for LCBDE. Four general surgical approaches were proposed to expose the common bile duct, including the ligamentum teres hepatis approach, the anterior hepatic duodenal ligament approach, the right hepatic duodenal ligament approach, and the hybrid approach. Additionally, this study highlighted seven crucial anatomical landmarks: the parietal peritoneum, the gastrointestinal serosa, the ligamentum teres hepatis, the inferior margin of the liver, the gastric antrum, the duodenum, and the hepatic flexure of the colon, which were helpful to safely separate abdominal adhesions and expose the common bile duct. Moreover, to shorten the time of choledocholithotomy, a sequential method was innovatively applied for the removal of the stones in common bile duct. Mastering the above surgical approaches, including identifying crucial anatomical landmarks and adopting the sequential method will improve the safety of reoperation for LCBDE, shorten the operation time, promote the fast recovery of patients, reduce postoperative complications, and contribute to the popularization and application of this technique.

Programmed surgery based on surgical methods and anatomical markers helps shorten the operation time, reduce complications, and improve the safety of the surgery. This study investigated and summarized the surgical methods and anatomic markers of laparoscopic common bile duct exploration in patients with a history of biliary tract surgery.

Exploração Laparoscópica do Ducto Biliar Comum em Pacientes com História Prévia de Cirurgia das Vias Biliares

For recurrent choledocholithiasis, abdominal adhesions in previous surgeries lead to changes in anatomical structures, and a secondary injury occurs ...

Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative asoedema, hematoma, sustaining pain, and seminal tract obstruction in patients who have undertaken nonmicroscopic epididymal cyst resection or epididymal resection. Nonmicroscopic epididymal cyst surgery is suggested for patients with childbirth plans as a precaution. The treatment of male epididymal cysts via microtechnology is obviously a beneficial option; we took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled &#34;microscopic epididymal exploration and cystectomy&#34;. The postoperative follow-up lasted for 3-50 months. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. Bleeding during the operation was significantly reduced (2-3 mL) and wound drainage was not required. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention. Besides, preliminary experience and reflection suggest that microscopic epididymal exploration and cystectomy provide efficient preservation of the epididymal patency through refined treatment, while a better prognosis can be achieved. We recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (&#62;0.9 cm in diameter) could cause the complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.

Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Ressecção de Cisto Microscópico para Tratamento de Pacientes Diagnosticados com Cisto Epididimal

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative ...

Aprimorando a reabilitação do AVC com treinamento ocupacional baseado em realidade virtual

Cognitive Function and Upper Limb Rehabilitation Training Post-Stroke Using a Digital Occupational Training System

Stroke rehabilitation often requires frequent and intensive therapy to improve functional recovery. Virtual reality (VR) technology has shown the potential to meet these demands by providing engaging and motivating therapy options. The digital occupational training system is a VR application that utilizes cutting-edge technologies, including multi-touch screens, virtual reality, and human-computer interaction, to offer diverse training techniques for advanced cognitive capacity and hand-eye coordination abilities. The objective of this study was to assess the effectiveness of this program in enhancing cognitive function and upper extremity rehabilitation in stroke patients. The training and assessment consist of five cognitive modules covering perception, attention, memory, logical reasoning, and calculation, along with hand-eye coordination training. This research indicates that after eight weeks of training, the digital occupational training system can significantly improve cognitive function, daily living skills, attention, and self-care abilities in stroke patients. This software can be employed as a time-saving and clinically effective rehabilitation aid to complement traditional one-on-one occupational therapy sessions. In summary, the digital occupational training system shows promise and offers potential financial benefits as a tool to support the functional recovery of stroke patients.

Autor em destaque: Reabilitação de pacientes com AVC com um sistema digital de treinamento ocupacional

The current protocol outlines how the VR-based digital occupational training system enhances the rehabilitation of patients with cognitive impairment and upper limb dysfunction following a stroke.

Função cognitiva e treinamento de reabilitação do membro superior pós-acidente vascular cerebral utilizando um sistema de treinamento ocupacional digital