Detection of unsuspected cases of nosocomial transmission of tuberculosis by use of a molecular typing method

The aim of this study was to use restriction fragment length polymorphism to detect unsuspected cases of nosocomial transmission of tuberculosis (TB) among patients who had been admitted to a university hospital. One hundred fifty-one samples of Mycobacterium tuberculosis isolated from patients with pulmonary TB were studied. The isolates from 37 patients (24.5%) defined 11 clusters. None of the patients infected with these cluster isolates had hospital stays that coincided with one another, and for 5.4% of the patients, the epidemiological link was clearly outside the hospital. Previous incarceration was associated with infection with cluster isolates. In addition, 109 patients without TB (41 of whom were infected with human immunodeficiency virus) who shared a room with patients who had TB were followed for 18-60 months. Among the patients who survived, secondary cases of TB due to nosocomial transmission were not detected.

Preliminary data of a prospective study on neuropsychiatric side effects after initiation of efavirenz

OBJECTIVE

To assess baseline variables able to predict neuropsychiatric side effects (NPSEs) associated with the initiation of an efavirenz (EFV)-containing regimen in HIV-1-infected patients.

DESIGN

Open-label, prospective, observational study.

METHODS

Consecutive HIV-1-infected outpatients in whom EFV was prescribed underwent a psychiatric interview. At baseline and at 2, 4, and 12 weeks, patients completed the Symptoms Check List-90-Revised (SCL-90-R), the Medical Outcome Study for HIV-positive patients (MOS-HIV), and a standardized questionnaire concerning potential NPSEs.

RESULTS

Preliminary data showed that discontinuation of EFV because of NPSEs occurred in 4 of 31 patients (13%). Patients who completed the follow-up showed a decrease in SCL-90-R total score (p =.004) and in several subscales such as Interpersonal Sensitivity (p =.009), Depression (p =.001), and Anxiety (p =.040), whereas no changes in MOS-HIV were observed. Having fewer years of education (p =.006), having fewer baseline central nervous symptoms (p =.000), reporting better baseline physical status (p =.013), and having higher baseline scores in the Heath Transition subscale of the MOS-HIV (p =.000) and in the Somatization subscale of the SCL-90-R (p =.002) were associated with more NPSEs.

CONCLUSION

Patients maintained on EFV showed a decrease in psychologic distress related to self-image, depression, and anxiety, without any effect on quality of life. Patients with a lower level of education, those who feel physically and psychologically better at baseline than in the past, and those who suffer from more distress as a result of physical complaints may be at greater risk of reporting more NPSEs after EFV initiation.

Strategies for treating HIV-related lipodystrophy

HIV-related lipodystrophy has emerged as one of the most prevalent problems for patients with HIV, since this infection can now be seen as a chronic disease. Despite its growing importance, crucial issues such as aetiopathogenesis, diagnosis, prevention and therapy remain largely unknown and unexplored. Current evidence suggests that aetiology is multifactorial. HIV infection, antiretroviral therapy and patient-related factors probably all contribute to the development of lipodystrophy. The lack of a formal definition and the nature of wasting syndromes that affect HIV-infected patients can hinder the diagnosis and treatment of lipodystrophy. Body fat changes have a major negative impact on the quality of life of patients. Metabolic abnormalities are also well known cardiovascular risk factors that can increase the morbidity and mortality due to cardiovascular disorders in a relatively young population. As yet, we do not know whether lipodystrophy is preventable or reversible. Several therapeutic approaches have been tested with limited success, however potential complications must be considered. These therapeutic approaches include general health measures (diet, exercise and discontinuation of smoking), switching antiretrovirals (from protease inhibitors to non-nucleoside reverse transcriptase inhibitors or abacavir, or from stavudine to other nucleoside reverse transcriptase inhibitors) and use of drugs with metabolic effects (metformin, thiazolidinediones, recombinant growth hormone and anabolic steroids). A judicious use of available data, and opting for an individualised approach seems the best option for management of this problem at present.

Hepatotoxicity in HIV-1-infected patients receiving nevirapine-containing antiretroviral therapy

OBJECTIVES

To assess the incidence and risk factors for hepatotoxicity associated with nevirapine.

DESIGN

A prospective cohort study in a teaching and referral hospital involving all consecutive patients who were prescribed a nevirapine-containing antiretroviral regimen between September 1997 and May 2000.

METHOD

Cutaneous and hepatic adverse reactions and clinical hepatitis were assessed. Blood analysis including plasma HIV-1 RNA CD4 cell counts, liver chemistry tests, and serology for hepatitis B and C viruses. Hepatotoxicity was defined as an increase of at least threefold in serum alanine aminotransferase or aspartate aminotransferase levels compared with baseline values.

RESULTS

Of a total of 610 patients, 82 (13.4%) were antiretroviral naive when commencing nevirapine, and 46.2 and 8.9% were coinfected with hepatitis C and B viruses, respectively. Median duration of exposure to nevirapine was 8.7 months (interquartile range 3.4--14.3). Hepatotoxicity developed in 76 (12.5%), an incidence of 13.1/100 person-years. Kaplan--Meier estimated incidence of hepatotoxicity at 3, 6 and 12 months was 3.7, 9.7 and 20.1%, respectively. In seven (1.1%) patients, hepatotoxicity was associated with clinical hepatitis, which was reversible upon discontinuation of therapy. Multivariate analysis identified the duration of prior exposure to antiretroviral drugs, hepatitis C virus, and higher baseline levels of alanine aminotransferase as independent risk factors for hepatotoxicity.

CONCLUSIONS

Hepatotoxicity but not clinical hepatitis was common in HIV-1-infected patients receiving nevirapine-containing regimens and the incidence steadily increased over time. Prolonged exposure to any antiretroviral therapy, coinfection with hepatitis C virus and abnormal baseline levels of alanine aminotransferase identified patients at a higher risk.

Biological and mechanistic activities of xanthorrizol and 4-(1',5'-dimethylhex-4'-enyl)-2-methylphenol isolated from Iostephane heterophylla

Xanthorrizol (1) and 4-(1',5'-dimethylhex-4'-enyl)-2-methylphenol (2) were identified as the principal antimicrobial components of a CH(2)Cl(2)-MeOH (1:1) extract derived from Iostephane heterophylla. Compound 2 is a new natural product, but has been synthesized. Both compounds exhibited low level activity (MICs of 16-32 microg/mL) against methicillin-resistant staphylococci and vancomycin-resistant enterococci. They were either inactive or poorly active against Gram-negative bacteria and yeast. Mechanistic studies performed in Escherichia coli imp suggested nonspecific inhibition of DNA, RNA, and protein synthesis by both of these compounds. Compound 1 was tested in an in vivo model; it did not provide protection to mice infected with Staphylococcus aureus.

[Cor triatriatum associated with Wolff-Parkinson-White syndrome]

Several anatomic anomalies have been associated with the Wolff-Parkinson-White syndrome. However, its association with cor triatriatum has never been previously established. We present a case report on a 34-year-old woman patient with paroxysmic palpitations and data of ventricular preexcitation seen on electrocardiogram. The presence of non-obstructive cor triatriatum was observed during echocardiographic valoration prior to radiofrequency catheter ablation.

Initial risk class and length of hospital stay in community-acquired pneumonia

The total medical costs of community-acquired pneumonia are directly related to the costs of hospital admission and length of stay. The aim of the present study was to evaluate the reasons for prolonged duration of stay in patients stratified in five risk classes for death, and to identify factors associated with prolonged stay. The study population consisted of 295 patients. According to lower (classes I, II, III) or to higher (classes IV, V) risk, the target duration of hospitalization was set at 5 and 7 days, respectively. The causes of prolonged hospitalization were classified as pneumonia-related, complications, unstable comorbid diseases and nonclinical factors. The overall percentage of patients with appropriate duration of hospitalization was 32%. Causes of prolonged hospitalization were related mainly to pneumonia (32%) from all risk classes. Morbid complications and instability of the underlying illness were greater in class V patients. Nonclinical factors were present in 29.5% of cases. Hypoxaemia, anaemia, hypoalbuminaemia, and complications appearing before 72 h were associated with prolonged hospitalization. The cause of prolonged hospitalization of patients with community-acquired pneumonia is multifactorial, depending mainly on pneumonia and comorbid conditions but there is a large number of unnecessary hospitalization days that could be reduced by improving the efficiency of hospital care.

Low flow veno-venous ECMO via subclavian dialysis catheter for severe respiratory failure

BACKGROUND

We present the case of a 12-year-old female with severe postoperative bacterial pneumonia unresponsive to conventional treatment following a failed renal transplant.

CASE REPORT

The patient was placed on low flow veno-venous extracorporeal membrane oxygenation (ECMO) as an adjuvant treatment to antibiotic therapy and maximal ventilatory support. Venous ECMO resulted in rapid improvement and the patient was successfully weaned after 48 hours of circulatory assistance. Two days later, the patient was extubated and safely discharged from the intensive care unit. Eighteen months later, she remains stable on peritoneal dialysis and is awaiting a new donor kidney.

CONCLUSIONS

Low flow veno-venous ECMO represents a new therapeutic alternative for critically ill patients whose condition does not meet the conventional ECMO criteria. Further clinical experience is still needed.

Inhibitory activity of xanthine-oxidase and superoxide scavenger properties of Inga verna subsp. affinis. Its morphological and micrographic characteristics

Hexane, dichloromethane and ethanolic extracts of Inga verna subsp. affinis were evaluated as inhibitors of xanthine-oxidase and as scavengers of the superoxide produced by the action of the enzyme. Ethanolic but not hexane and dichloromethane extracts showed inhibitory properties of xanthine-oxidase (IC50=27.3 microg/ml) with an additional superoxide scavenging capacity (IC50=12.7 microg/ml). The antioxidant potential was confirmed with the free radical 1,1-diphenyl-2-picryl hydrazyl (DPPH) assay, which showed that the ethanolic extract scavenges 50% DPPH free radicals at 11.6 microg/ml. HPLC study of the phenol content of the active extract, revealed the presence of ellagic and gallic acids as its main constituents. The main morphological and micrographic characteristics of Inga verna subsp. affinis are described in this paper too, in order to aid in its inequivocal identification since Inga spp. are noted for their morphological variation, which makes taxonomic classification very difficult.

Prosthetic vascular graft infection due to Aspergillus species: case report and literature review

A case of Aspergillus prosthetic graft infection is reported here, accompanied by a review of the literature on this topic. The literature search revealed only 13 other cases reported to date. This infection is usually acquired through contamination at the time of surgery and affects immunocompetent patients. Aspergillus fumigatus is the causative species in most cases. Remarkably, fever is absent in about one-half of all cases, and blood cultures are usually negative. Concomitant vertebral osteomyelitis is commonly observed when the aorta is involved. Cure of this serious infection may be achieved with antifungal therapy, excision of the infected graft and extra-anatomic bypass.

Polyamines in the basal ganglia of human brain. Influence of aging and degenerative movement disorders

The distribution of polyamines in the human basal ganglia was examined, using dansyl-derivatives and high pressure liquid chromatography with fluorimetric detection. A heterogeneous distribution of putrescine, spermidine (SD) and spermine (SM) was observed in control brains. A consistent negative correlation between SD and SM content and age was found in different brain areas. These results suggest an involvement of polyamines in age-related changes occurring in white-matter. When the influence of degenerative movement disorders -Parkinson's disease, Huntington's disease (HD) and progressive supranuclear palsy- was analyzed, significant changes were observed only in HD, where a decrease in the concentration of SM was found in the putamen. These results suggest that in advanced stages of neurodegenerative processes, polyamines maintain their regulation. Only in the presence of severe atrophy, SM concentration is reduced.

[Infantile bilateral striate necrosis]

INTRODUCTION

Necrosis of the basal ganglia (NBG) is an uncommon condition in childhood. Cases of NBG have been reported in connection with metabolic disorders, infections, degenerative conditions, intoxications, head injuries and hypoxic-ischemic encephalopathies. The commonest clinical features include alteration of consciousness, chorea-athetoic or dystonic movements, spasticity, contractures of the limbs and convulsions.

CLINICAL CASE

We describe the case of an eight year old girl, who after having clinical gastroenteritis, developed acute neurological dysfunction, associated with images on cranial computerized axial tomography (CAT) showing a possible intracranial tumour and magnetic resonance (MR) studies showing bilateral hypodensity of the basal ganglia. Three months later magnetic resonance showed that these lesions had almost completely disappeared. This supports the diagnosis of post-infectious lesions.

CONCLUSIONS

The clinical course is very variable. Cases with a previous history of infection have a better prognosis. In our patient treatment was started with corticosteroids. She made a good recovery and was sent home with no sequelae five days later. The new imaging techniques (CAT and MR) have led to more cases of selective involvement of the basal ganglia being diagnosed. MR is the most specific technique for diagnosis in these patients. Although there is no effective specific treatment, treatment with biperidine, thyrotropic hormone and corticosteroids have been used with no apparent effect on the course of the disorder.

New rapid antigen test for diagnosis of pneumococcal meningitis

Conventional diagnostic methods for bacterial meningitis are frequently not rapid or sensitive enough to guide initial antimicrobial therapy. Streptococcus pneumoniae is the most frequent and severe cause of community-acquired bacterial meningitis and treatment is complicated by the increasing prevalence of antimicrobial resistance to third-generation cephalosporins. We used a new rapid antigen test in the cerebrospinal fluid and urine of patients with suspected bacterial meningitis, and found it to be highly sensitive and specific for the detection of pneumococci. This test might help guide initial therapy for bacterial meningitis according to the local rates of pneumococcal antimicrobial resistance.

Thrombotic microangiopathy as a cause of dilated cardiomyopathy in HIV-infected patients

Thrombotic microangiopathy is a rare cause of dilated cardiomyopathy. Both entities have been described separately in the setting of HIV infection. However, no patient with these 2 conditions has been reported to date. We report here 2 HIV-infected patients with dilated cardiomyopathy seemingly caused by thrombotic microangiopathy.

Polymorphisms of the repeated sequences in the enhancer region of the thymidylate synthase gene promoter may predict downstaging after preoperative chemoradiation in rectal cancer

PURPOSE

Thymidylate synthase (TS) is an important target enzyme for the fluoropyrimidines. TS gene promoter possesses regulatory tandemly repeated (TR) sequences that are polymorphic in humans, depending on ethnic factors. These polymorphisms have been reported to influence TS expression. TS expression levels affect tumor downstaging after preoperative fluoruracil (5-FU)-based chemoradiation. Tumor downstaging correlates with improved local control and disease-free survival. The aim of this study is to correlate TR polymorphisms with downstaging and disease-free survival.

PATIENTS AND METHODS

Sixty-five patients with rectal cancer underwent tumor resection after preoperative 5-FU-based chemoradiation. Tumor downstaging was evaluated by comparing the pretreatment T stage with the pathologic stage observed in the surgical specimen. TS polymorphism genotype was determined by polymerase chain reaction amplification of the corresponding TS promoter region, and products of amplification were electrophoresed, obtaining products of 220 bp (2/2), 248 bp (3/3), or both (2/3). The TS polymorphism genotype results were subsequently compared with the downstaging observed and with disease-free survival.

RESULTS

Patients who were homozygous for triple TR (3/3) had a lower probability of downstaging than patients who were homozygous with double TR or heterozygous patients (2/2 and 2/3): 22% versus 60% (P =.036; logistic regression). Furthermore, a trend toward improved 3-year disease-free survival was detected in the 2/2 and 2/3 groups, compared with that in the 3/3 group (81% v 41%; P =.17).

CONCLUSION

This preliminary study suggests that TS repetitive-sequence polymorphisms are predictive for tumor downstaging. TR sequences in TS promoter may be useful as a novel means of predicting response to preoperative 5-FU-based chemoradiation.

Facial superficial porokeratosis

A case of exclusively facial superficial porokeratosis occurring in a young man is reported. These lesions were asymptomatic and remarkable because of their location. Histopathology revealed a typical superficial porokeratosis. Exclusively facial porokeratosis is an unusual clinical presentation. To our knowledge, it is the second report of a case with exclusively facial involvement.

Cavernous hemangioma of the thyroid

Most current vascular alterations of the thyroid are connected with the organization of a thyroid hematoma after fine-needle aspiration (FNA). Cavernous hemangioma is a benign congenital vascular malformation that occasionally affects the thyroid. This article presents two cases of this rare thyroid pathology unrelated to FNA.

A randomized trial of the discontinuation of primary and secondary prophylaxis against Pneumocystis carinii pneumonia after highly active antiretroviral therapy in patients with HIV infection. Grupo de Estudio del SIDA 04/98

BACKGROUND

Prophylaxis against Pneumocystis carinii pneumonia is indicated in patients with human immunodeficiency virus (HIV) infection who have less than 200 CD4 cells per cubic millimeter and in those with a history of P. carinii pneumonia. However, it is not clear whether prophylaxis can be safely discontinued after CD4 cell counts increase in response to highly active antiretroviral therapy.

METHODS

We conducted a randomized trial of the discontinuation of primary or secondary prophylaxis against P. carinii pneumonia in HIV-infected patients with a sustained response to antiviral therapy, defined by a CD4 cell count of 200 or more per cubic millimeter and plasma HIV type 1 (HIV-1) RNA level of less than 5000 copies per milliliter for at least three months. Prophylactic treatment was restarted if the CD4 cell count declined to less than 200 per cubic millimeter.

RESULTS

The 474 patients receiving primary prophylaxis had a median CD4 cell count at entry of 342 per cubic millimeter, and 38 percent had detectable HIV-1 RNA. After a median follow-up period of 20 months (758 person-years), there had been no episodes of P. carinii pneumonia in the 240 patients who discontinued prophylaxis (95 percent confidence interval, 0 to 0.85 episode per 100 person-years). For the 113 patients receiving secondary prophylaxis, the median CD4 cell count at entry was 355 per cubic millimeter, and 24 percent had detectable HIV-1 RNA. After a median follow-up period of 12 months (123 person-years), there had been no episodes of P. carinii pneumonia in the 60 patients who discontinued prophylaxis (95 percent confidence interval, 0 to 4.5 episodes per 100 person-years).

CONCLUSIONS

In HIV-infected patients receiving highly active antiretroviral therapy, primary and secondary prophylaxis against P. carinii pneumonia can be safely discontinued after the CD4 cell count has increased to 200 or more per cubic millimeter for more than three months.

Regression of infancy hemangiomas with recombinant IFN-alpha 2b

Interferon-alpha (IFN-alpha) has antitumor and antiangiogenic effects. The purpose of this work was to evaluate its efficacy and safety in the treatment of infancy hemangioma and to monitor the appearance of anti-IFN antibodies in these patients. Thirty-nine children (29 girls) aged 1.5-158 months, with 19 younger than 1 year and 9 older than 5, were treated with 3 x 10(6) IU/m(2) IFN-alpha 2b, subcutaneously (s.c.) daily. Inclusion criteria were life-threatening or life-limiting hemangioma and parents' informed consent. Regression was considered if tumor size diminished by 50% or more. Of the 38 patients who completed 6 months of treatment, 27 (71.1%) had regression and 11 (28.9%) had stable disease. No patient experienced progression. Regression was more frequent (100%) among patients between 1 and 5 years old, but it was particularly important (68%) among those under 1 year old, when spontaneous regression is rare. The main side effects were the IFN-related flulike syndrome (79%), increase in serum alanine aminotransferase (ALT) (28%), anorexia (19%), and mild inflammation at the injection site (19%). There was no effect on psychomotor or physical development. On the contrary, 1 patient with neurologic symptoms improved remarkably, including seizure disappearance. Eight patients developed anti-IFN-alpha 2 neutralizing antibodies, and 7 of them responded to IFN treatment. IFN-alpha 2b is a safe and efficacious treatment of infancy hemangioma. Further work should look for other treatment schedules and ways of administration and carefully monitor anti-IFN neutralizing antibodies, which does not seem to interfere with response.

Iatrogenic cost factors incorporating mild and moderate adverse events in the economic comparison of aceclofenac and other NSAIDs

OBJECTIVE

To perform a modelled economic analysis of the efficacy and tolerability of aceclofenac in comparison with those of other nonsteroidal antiinflammatory drugs (NSAIDs) used in the treatment of common arthritic disorders including osteoarthritis, rheumatoid arthritis and ankylosing spondylitis.

DESIGN

A decision analytical model was constructed to represent the clinical and economic consequences of NSAID treatment. Probabilities of noncompliance, lack of efficacy and incidence of adverse events were obtained from comparative randomised double-blind clinical trials. Local unit treatment costs were used and an expert panel was convened to estimate resource use. Both classical foldback analysis and bootstrap methods were used to compute point estimates and 95% confidence limits of costs for NSAID treatment.

PATIENTS AND INTERVENTIONS

Data were obtained from 12 randomised double-blind clinical trials included in an earlier meta-analysis.

MAIN OUTCOME MEASURES

Total costs to the healthcare provider, including NSAID treatment costs (drug acquisition costs and physician visits for prescription) and iatrogenic costs (substitution treatment costs for patients not achieving clinical efficacy and costs of medical visits, treatment, diagnostic tests and hospital stays associated with adverse events) and the iatrogenic cost factor (ICF) were used as the primary outcome measures.

RESULTS

Means and 95% confidence intervals revealed no statistically significant differences in total costs between aceclofenac and other NSAIDs, with the exception of piroxicam, despite substantial differences in drug acquisition costs. The ICF for aceclofenac was lower than that for all other comparators, and differences in ICF between aceclofenac 200 mg/day and diclofenac 150 mg/day, indomethacin 100 mg/day, naproxen 1000 mg/day, tenoxicam 20 mg/day or ketoprofen 150 mg/day were statistically significant.

CONCLUSION

These results show that the comparative overall costs of NSAIDs bears little relation to drug acquisition cost, and that the ICF is one of the most important determinants of overall costs.