Developing a researchable question is one of the challenging tasks a researcher encounters when initiating a project. Both, unanswered issues in current clinical practice or when experiences dictate alternative therapies may provoke an investigator to formulate a clinical research question. This article will assist researchers by providing step-by-step guidance on the formulation of a research question. This paper also describes PICO (population, intervention, control, and outcomes) criteria in framing a research question. Finally, we also assess the characteristics of a research question in the context of initiating a research project.

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Adolescence (10- 19 years) is a phase of physical growth and development accompanied by sexual maturation, often leading to intimate relationships. Adolescent HIV/AIDS is a separate epidemic and needs to be handled and managed separately from adult HIV. The adolescents can be subdivided into student, slum and street youth; street adolescents being most vulnerable to HIV/AIDS. Among various risk factors and situations for adolescents contracting HIV virus are adolescent sex workers, child trafficking, child labor, migrant population, childhood sexual abuse, coercive sex with an older person and biologic (immature reproductive tract) as well as psychological vulnerability. The most common mode of transmission is heterosexual, yet increasing number of perinatally infected children are entering adolescence. This is due to "bimodal progression" (rapid and slow progressors) among the vertically infected children. Clinically, the HIV infected adolescents present as physically stunted individuals, with delayed puberty and adrenarche. Mental illness and substance abuse are important co-morbidities. The disclosure and declaration of HIV status to self and family is challenging and guilt in sexually infected adolescents and tendency to blame parents if vertically affected need special consideration and proper counseling. Serodiscordance of the twins and difference in disease progression of seroconcordant twins are added causes of emotional trauma. Treatment related issues revolve around the when and what of initiation of ART; the choice of antiretrovirals and their dosages; issues related to long term ADRs; sense of disinhibition following ART commencement; adherence and resistance.

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Background: Tenofovir (TDF) is preferred nucleoside reverse transcriptase inhibitors (NRTI) for the treatment of human immunodeficiency virus infection because of its potency and safety. Renal toxicity with TDF use is low and comparable with other NRTI in clinical trials, but there are many case studies and small case series of renal dysfunction with TDF. Materials and Methods: This is an observational longitudinal cohort of patients started on a TDF-based regimen from January 2007 to April 2010. Patients were evaluated at baseline and with every follow-up visit for serum creatinine and calculated creatinine clearance (Cockroft-Gault formula). In addition to this, the patients were also subjected to test for serum potassium, phosphorous and urine examinations as and when indicated. Renal dysfunction was defined as rise in serum creatinine to more than the upper level of normal (>1.2 mg%). Results: Of 1,271 patients started on a TDF-containing antiretroviral treatment (ART) 83 (6.53%) developed renal dysfunction, of which 79 had impaired serum creatinine and five had Fanconi's syndrome. Renal dysfunction was more common with boosted a protease inhibitor (PI) (9.44%)-based regimen as compared to a non- nucleoside reverse transcriptase inhibitors (NNRTI) (5.01%)-based regimen (P = 0.003). The mean decline in creatinine clearance from baseline was 22.27 ml/min. The median time to develop renal dysfunction was 154 (15-935) days. Serum creatinine returned to normal in all the patients after stopping TDF. Five patients presented with features suggestive of Fanconi's syndrome without alteration in serum creatinine. Conclusion: TDF-based treatment is associated with mild but reversible renal dysfunction. Patients receiving PI/r are at a higher risk of renal dysfunction compared to those receiving NNRTI-based ART. Clinicians should be adviced to have intensive renal monitoring, including creatinine clearance, urine examination, K+ and phosphate levels at baseline and during treatment with TDF.

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Aims: To determine the seroprevalence of herpes simplex type 2 (HSV-2) infection in pregnant females, assess the frequency of unrecognized infection and identify the demographic profile and risk factors associated with the seroprevalence. Materials and Methods: Two hundred randomly selected, asymptomatic pregnant females attending the Obstetrics and Gynecology Outpatient Department for a routine antenatal check-up constituted the study group. Serum specimens were screened for HSV-2 infection by detecting IgG class antibodies against HSV-2-specific glycoprotein G-2 using an enzyme-linked immunosorbent assay kit. Results: A seroprevalence of 7.5% was found in our study. Seropositivity was maximum in the age group ≥30 years (22.20%), followed by 26-30 years (9.7%), 21-25 years (2.20%) and ≤20 years (0%). HSV-2 seropositivity was found to be significantly associated with increasing age, parity, number of sexual partners, duration of sexual activity and history of abortions (P < 0.05). No statistically significant correlation was observed between seropositivity and other demographic variables such as place of residence, education, annual family income and occupation (P > 0.05). No statistically significant association of seropositivity with present or past history suggestive of other sexually transmitted infections was found. None of our cases tested positive for human immunodeficiency syndrome (HIV). Conclusion: A relatively low prevalence of HSV-2 seropositivity was found in our study, with a high frequency of unrecognized and asymptomatic infections. Our findings suggest that type-specific serotesting could be an efficient strategy to diagnose clinically asymptomatic HSV-2 infections and, therefore, to reduce the risk of HSV-2 and HIV sexual transmission by prophylactic counseling against unprotected intercourse. It may also be a useful adjunct in detecting cases who present with symptoms not directly suggestive of genital herpes.

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Introduction: Cryptococcal meningitis is one of the acquired immunodeficiency syndrome defining infections with high mortality. Amphotericin B is the preferred drug for induction therapy. Despite advances in human immunodeficiency virus (HIV) treatment, Antiretroviral Treatment (ART) roll-out programs and availability of amphotericin B, cryptococcal meningitis remains an important cause of mortality in the African and other developing countries. Materials and Methods: We carried out a prospective observational study to determine the treatment response rate, tolerability and outcome of patients with cryptococcal meningitis in HIV treated with amphotericin B. Descriptive statistic was used to analyze the data. Results: A total of 27 patients were diagnosed with cryptococcal meningitis during the study period. Headache (96.29%) was the single most common presenting symptom of cryptococcal meningitis in HIV-infected patients, followed by vomiting (77.77%) and fever (66.66%). Cerebrospinal fluid (CSF) routine and microscopic examination was within normal limits in six patients. CSF became sterile on the 12th day of Amphotericin B in 55.55% of the patients while 33.33% had positive CSF cultures. Patients were started with ART after achieving sterile CSF and tolerated at least 2 weeks of fluconazole consolidation treatment and were free from symptoms. Median time for antiretroviral treatment initiation was 35 (14-90) days after completion of Amphotericin B treatment. One patient developed immune reconstitution inflammatory syndrome (IRIS) after ART. Conclusions: We found that the recommended 2 weeks induction treatment with Amphotericin B monotherapy for HIV patients with cryptococcal meningitis in resource-limited settings may be suboptimal for at least one-third of the patients. Extending the therapy to 3 weeks is likely to result in sterilization of the CSF in a majority of these patients. This finding requires confirmation by a larger sample size in appropriately powered studies. Delaying ART initiation by at least 2 weeks after amphotericin B treatment may decrease the incidence of IRIS.

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Cutaneous leishmaniasis and human immunodeficiency virus (HIV) co-infection is emerging as increasingly frequent and serious new disease. Leishmaniasis may be acquired before or after HIV infection. We describe two cases of post-kala-azar dermal leishmaniasis in HIV-positive patients. Both the patients had papulonodular lesions on upper extremities and back with low CD4 count. Slit skin smear with giemsa stain revealed Leishman Donovan (LD) bodies and skin biopsy of both the patients revealed lymphohistiocytic infiltrate with numerous intracytoplasmic LD bodies.

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Hidradenitis suppurativa (HS) is a disorder of the terminal follicular epithelium in the apocrine gland-bearing skin, characterized by comedo-like follicular occlusion, chronic relapsing inflammation, mucopurulent discharge, and progressive scarring. In this study, we report a case of 35-year-old HIV-positive man with recurrent nodular skin lesions with foul smelling discharge over face, gluteal region, thighs, and axilla. This case is unique because of its association with HIV leading to atypical manifestations and therapeutic challenges.

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Emergency departments (EDs) receive patients from every background, socioeconomic group and health status. Hence, EDs can play a critical role in offering human immunodeficiency virus (HIV) testing and help in the national strategy of early HIV detection. The present study was conducted on 400 patients attending various EDs after taking Institutional Review Board approval. They were screened for HIV antibodies by three rapid/simple assay tests having different principles/antigens as per the NACO guidelines. Twenty-three (5.75%) of the 400 patients were HIV reactive. Fifteen (65.22%) of the 23 HIV-reactive patients were unaware of their reactive status. Majority of the HIV-reactive (65.22%) patients were from the Medicine emergency followed by Orthopaedics and Surgery (13.04%). Seven (30.43%) had history of fever of more than 1 month duration. Eight (34.78%) of them were later on clinically diagnosed as having various opportunistic infections. Thus, the study emphasizes the need for expansion of routine voluntary HIV counseling and testing to all the patients who come to the ED and practicing universal work precautions by health care workers.

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Mycetoma is a chronic, granulomatous disease of the skin, and subcutaneous tissue, which sometimes involves muscle, bones, and neighboring organs. It is characterized by tumefaction, abscess formation, and fistulae with discharge of grains from sinuses. Mycetoma can be caused by various species of fungi (eumycetoma) and aerobic actinomycetes (actinomycetoma), which occur as saprophytes in soil or plants. A tentative diagnosis sufficient to initiate treatment may be made on the basis of grain color. For instance, melanoid grains are always caused by fungi and ochroid or pale grains by actinomycetes. Although this is not the thumbrule, there are exceptional reports too. As trauma favors infection, most lesions are on the foot and lower leg but they may occur anywhere on the body mimicking actinomycosis. However, lab investigations and culture are important tool to differentiate apart from the clinical picture. We are reporting atypical case with unusual site of presentation (perineum and thigh) of mycetoma.

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We report a case of disseminated histoplasmosis in a 37-year-old male acquired immunodeficiency syndrome patient from south India. The patient presented with high-grade fever, cough, conjunctival nodule and papulonodular hyperpigmented skin lesions. Histology of skin lesions and conjunctival nodule showed numerous intracellular Periodic Acid Schiff-positive rounded yeast cells within macrophages. Bone marrow aspirate confirmed disseminated histoplasmosis. The patient showed dramatic response after starting treatment with Amphotercin B.

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Purpose: The aim of our study was to evaluate whether perirenal fat thickness (PRFT), a parameter of central obesity, is related to kidney function and intrarenal artery resistive index (IARI) in human immunodeficiency virus (HIV)-1-infected patients. Materials and Methods: We enrolled 102 consecutive HIV-1-infected patients receiving highly active antiretroviral therapy for more than 12 months in a prospective cohort study. Echographically, the PRFT and IARI were measured and the serum metabolic parameters were evaluated. PRFT and IARI were measured using a 3.75 MHz convex linear probe. Results: The mean of PRFT and IARI in HIV-1-infected patients with visceral obesity was considerably higher than that in patients without it (P <0.001 and <0.01, respectively). Using the average IARI as the dependent variable, age (odds ratio, 1.07; 95% confidence interval [CI], 1.01-1.14; P < 0.5) and PRFT (odds ratio, 1.28; 95% CI, 1.08-1.51; P<0.01) were independent factors associated with IARI. Conclusion: Our data indicate that ultrasonographic assessment of PRFT may have a potential to be a marker of increased endothelial damage with specific involvement of the renal vascular district in HIV-1-infected patients.

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