A Case of Multiorgan Failure Following Interruption of Antiretroviral Treatment

Reported here is an exceptional case of acute retroviral syndrome resembling septic shock that occurred in a chronic HIV-infected patient shortly following planned interruption of antiretroviral treatment. The therapeutic strategy, which is aimed at improving the immunological control of HIV infection, can therefore be deleterious in chronically infected patients and should be avoided outside of closely monitored clinical trials.

Evaluation of the psychometric characteristics of the Spanish version of the Hospital Anxiety and Depression Scale

OBJECTIVE

To assess the psychometric properties of the Spanish version of the Hospital Anxiety and Depression Scale(HADS).

METHOD

We administered HADS to 685 participants (256 controls and 429 patients with five different diagnoses). The reliability of the instrument was assessed by a test-retest study. Construct validity studies were carried out through item-subscale correlation and factor analysis for the whole group and by each of the five different diagnoses. Three instruments were used as external criteria to assess concurrent validity.

RESULTS

HADS test-retest reliability presented correlation coefficients above 0.85. The internal consistency was high, with a Cronbach's alpha of 0.86 (anxiety) and 0.86 (depression). Factor analysis showed a clear two-factor structure for all groups. The results showed high concurrent validity with the Beck Depression Inventory and State-Trait Anxiety Inventory and with the mental domains of the Short-Form Health Survey.

CONCLUSION

The Spanish version of the HADS demonstrated good reliability and validity when used in medical patients.

Hyperhomocysteinemia in children with renal transplants

Many studies have demonstrated a strong association between elevated plasma total homocysteine (tHcys) levels and vascular disease. The aim of the present study was to determine the plasma levels of tHcys in pediatric recipients of renal transplants, to establish possible correlations with renal function, lipid profile, and folate and vitamin B12 status, and to assess whether the C677T and A1298C polymorphisms in the 5, l0-methylenetetrahydrofolate reductase (MTHFR) gene were associated with a particular risk. A total of 26 transplanted children and adolescents were investigated. tHcys levels were elevated in transplanted patients (12.9+/-4.8 micro mol/l) and 73% of these displayed values above the 97th percentile of healthy children. Plasma tHcys correlated negatively with creatinine clearance ( r=-0.58, P<0.001) and plasma vitamin B(12) ( r=-0.40, P<0.05) and positively with plasma triglycerides ( r=0.53, P<0.005). No significant correlations were found between plasma tHcys level and age, gender, time elapsed after transplantation and plasma values of glucose, insulin, folic acid, total cholesterol, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, apolipoprotein B, and apolipoprotein A-1. Plasma tHcys level was clearly increased in 3 patients with a MTHFR 677TT/1298AA genotype. In a multiple stepwise regression model plasma creatinine and triglyceride levels and MTHFR 677TT/1298 AA genotype accounted for 60% of the observed plasma tHcys variability. The MTHFR 677CT/1298 AC genotype was not a significant predictor of tHcys plasma levels. We conclude that a moderate degree of hyperhomocysteinemia is often present in renal transplant children and that folate supplementation must be considered in this population.

Two strategies for family intervention in schizophrenia: a randomized trial in a Mediterranean environment

Controlled intervention studies carried out in families of schizophrenia patients have been shown to have a positive impact in relapse prevention, but it remains to be seen whether different forms of family intervention affect outcomes other than relapse and hospital readmission in different ways. This study compared the outcome profile of relevant clinical variables after two different family intervention strategies for schizophrenia patients in public health care in a Spanish sample. We conducted a randomized controlled study comparing (1) a relatives group (RG) and (2) a single-family behavioral family therapy (BFT), both offered as standard treatment in one catchment area in Valencia. All randomized patients were included in the main analysis, and all cases remained in the therapy group to which they were originally assigned regardless of whether they suffered a relapse. The relapse rate at 12 months for the 87 cases studied was not significantly different in the two groups, but the two approaches did affect outcomes other than relapse and rehospitalization (such as social functioning, dose of antipsychotic medication, "delusions" and "thought disorder") in different ways. The BFT approach offered more advantages than the RG approach. The results suggest that these approaches should always be implemented in a clinical environment in a Mediterranean setting.

Homozygosity in Huntington's disease: new ethical dilemma caused by molecular diagnosis

Huntington's disease (HD) is a degenerative disorder of the central nervous system with autosomal dominant inheritance. Genetic counseling has always been difficult in this disorder with anguish, depression and denial being very common in both the patient and family members. The discovery of the causal gene has led to precise diagnostic procedures allowing homozygotes for the disease to be identified. Contrary to what occurs in some other autosomal dominant diseases, the course of the disease is not more severe in the homozygote than in the heterozygote. The present authors describe a family comparing two affected siblings: one is heterozygotic and the other homozygous for the HD mutation. They confirm that the age and symptoms of onset did not differ significantly between the subjects; however, the disease seemed to have a more severe progression in the heterozygote than in the homozygote. The authors discuss the ethical dilemma derived from the genetic counseling of a homozygotic patient, given the fact that all his offspring will be affected. Letting the offspring know about their 100% probability of inheriting the disorder is equivalent to delivering a non-requested predictive test, while not informing them constitutes withholding crucial information from the individual.

Pharmacokinetic interaction between nevirapine and rifampicin in HIV-infected patients with tuberculosis

To determine whether rifampicin reduces serum concentrations of nevirapine and whether nevirapine modifies serum concentrations of rifampicin, levels of these agents were determined at steady state by high-performance liquid chromatography in 10 HIV-infected patients with tuberculosis. The median area under the curve (AUC) 0-12h of nevirapine before and after rifampicin was 56.2 and 32.8 microg/ml per hour, respectively ( p =.04). This represents a 31% reduction in serum nevirapine concentrations. The C(max) decreased from 5.6 to 4.5 microg/ml ( p =.04), which represented a 36% reduction. A 21% decrease in the C(min) was not statistically significant. Exposure to rifampicin did not significantly differ between those patients who were receiving and were not receiving nevirapine. However, our study shows that rifampicin reduces serum exposure to nevirapine. The clinical implications for this reduction remain to be established. Given that the lowest trough serum concentration of nevirapine exceeded by more than 40 times the protein binding adjusted median infective dose (IC(50)) of wild-type HIV in all patients, we suggest that there is no need to increase nevirapine dosage when it is given with rifampicin.

Rifampin reduces concentrations of trimethoprim and sulfamethoxazole in serum in human immunodeficiency virus-infected patients

To determine whether rifampin reduces concentrations of trimethoprim (TMP) and sulfamethoxazole (SMX) in serum of human immunodeficiency virus (HIV)-infected persons, levels of these agents were determined by high-performance liquid chromatography before and after more than 12 days of standard antituberculosis treatment for 10 patients who had been taking one double-strength tablet of co-trimoxazole once daily for more than 1 month. Statistically significant, 47 and 23% decreases in TMP and SMX mean areas under the concentration-time curve from 0 to 24 h (AUC(0-24)), respectively, were observed after administration of rifampin. N-Acetyl-SMX profiles without and with rifampin were similar. The steady-state AUC(0-24) metabolite/parent drug ratio increased by 32% with rifampin administration. Our study shows that rifampin reduces profiles of TMP and SMX in serum of HIV-infected patients.

Interferon and ribavirin combination therapy for chronic hepatitis C in human immunodeficiency virus-infected patients with congenital coagulation disorders

We have conducted an open, prospective trial to assess the safety and efficacy of interferon alfa-2b and ribavirin in combination for the treatment of chronic hepatitis C in human immunodeficiency virus (HIV)-infected hemophiliacs. Twenty hemophiliacs coinfected with HIV and hepatitis C virus (HCV), 18 of them under highly active antiretroviral therapy (HAART), with a mean CD4(+) cell count of 490 +/- 176 cells/mm(3) and undetectable (n = 9) or low-level HIV RNA (<10,000 copies/mL; n = 11), were treated with interferon-alfa2b (3 MU thrice weekly) and ribavirin (800 mg/d) for 6 or 12 months according to virologic response. Patients were monitored for tolerance and response at 4, 8, 12, 24, 36, and 48 weeks during treatment and every other month thereafter. All 20 patients enrolled completed at least 6 months of treatment with no major side effect requiring treatment withdrawal, dose reduction, or modification of HAART. Overall, 8 patients (40%) achieved a sustained virologic response at the end of the 6-month post-treatment follow-up. Sustained responders had lower baseline HCV-RNA levels (5.7 +/- 0.8 vs. 6.3 +/- 0.4 log10 IU/mL, P =.041) but were otherwise similar to nonresponders. All sustained responders had a decrease in HCV-RNA level of at least 1 log per month during the first 2 months and undetectable levels at 6 months. In conclusion, our results provide evidence that combination therapy with interferon and ribavirin is safe in HIV-infected hemophiliacs with stable CD4 cell count and undetectable or low-level HIV replication, and leads to eradication of HCV in 40% of these patients.

Cefepime versus cefotaxime for empirical treatment of bacterial pneumonia in HIV-infected patients: an open, randomized trial

An open, randomized, multicentre clinical trial was conducted to compare the efficacy and safety of cefepime 2 g iv bd (2 g tds daily in cases of Pseudomonas aeruginosa pneumonia) with cefotaxime 2 g iv tds, in the empirical treatment of bacterial pneumonia in HIV-infected patients. The primary end-point was effectiveness after 3-5 days of treatment, taking success to be when the study drug was continued during this period of time. Clinical and bacteriological responses at end of treatment (EOT) were also evaluated. Analyses of the intention-to-treat population (n = 160) and the as-per-protocol groups (n = 150) were carried out. Treatment groups were comparable with regard to sex, age, HIV status and degree of severity of pneumonia. The primary end-point for cefepime was considered successful for the intention-to-treat and as-per-protocol groups in 85.7% and 93.5% of cases, respectively, and for cefotaxime, in 77.6% and 80.8% of cases, respectively (P = 0.22 and P = 0.02). In the as-per-protocol group, cefotaxime treatment was independently related to failure at the primary end-point. A satisfactory clinical response in the intention-to-treat population was observed in 83.3% of cefepime and 82.9% of cefotaxime patients. Bacteriological cure was obtained in 100% of evaluable cefepime and 93.4% of evaluable cefotaxime patients at EOT. Safety of the study drugs was comparable in both treatment groups. Cefepime 2 g iv bd was at least as effective and as well tolerated as cefotaxime 2 g iv tds in the treatment of bacterial pneumonia in HIV-infected patients.

[Reimplantation edema in the transplanted lung. Reperfusion-ischemia or hydrostatic edema?]

The development of non cardiogenic pulmonary edema or pulmonary reimplantation response after lung transplantation has been well described. The cause is ischemic vascular injury of the allograft, results in increased permeability of the lung after reperfusion, in turn leading to interstitial and alveolar edema. We report two cases of pulmonary reimplantation response after bilateral sequential lung transplantation. Massive pink frothy fluid was noted in the orifice of the double-lumen endobronchial tube. Blood and endobronchial fluid samples were collected for protein electrophoresis. We conclude that, in spite of the severity of reimplantation response, this complication can be resolved early when the cause is mainly hydrostatic.

Adjuvant anthracycline therapy as a prognostic factor in metastatic breast cancer

BACKGROUND

Prognostic factors in metastatic breast cancer continue to be identified. Previous adjuvant chemotherapy appeared to have poor prognosis in some studies but, despite this, the prior use of anthracyclines in the adjuvant setting has not been clearly established as an adverse prognostic factor once metastatic disease develops.

PATIENTS AND METHODS

Patients (n = 1,436) with stages I-IIIa breast cancer were surgically treated with/without radiotherapy and/or systemic adjuvant treatment. Of these, 297 patients who relapsed with metastatic disease constitute the sample population of this retrospective study. Survival, as a function of time since diagnosis of metastatic disease, was assessed in relation to the following factors: age, size of the primary tumor, grade, number of positive axillary nodes, type of surgery, type of adjuvant treatment administered, time to relapse, number of metastatic sites, presence of visceral metastases and type of treatment employed at the time of relapse.

RESULTS

In multivariable analysis three factors remained significant predictors of short survival time: more than 1 site of metastases (p = 0.00003), shorter time to relapse (p = 0.003) and the previous administration of anthracyclines as adjuvant therapy (p = 0.005).

CONCLUSIONS

The prior use of adjuvant anthracyclines, with other known clinical prognostic factors, confers a poorer outcome in metastatic disease, perhaps as a result of resistant clones selection or by induction of de novo resistance.

Simple and rapid determination of nevirapine in human serum by reversed-phase high-performance liquid chromatography

Nevirapine is an antiretroviral agent belonging to the class of non-nucleoside reverse transcriptase inhibitors. We describe a fast, simple isocratic reversed-phase high-performance liquid chromatography method with a 30-mm long column for assaying nevirapine in human serum. After deproteinization of 200 microl serum samples with 50% trichloroacetic acid, the supernatant was injected into a reversed-phase C18 column, using 10 mM phosphate buffer (pH 5)-acetonitrile (82:18, v/v) as the mobile phase. Peak detection was performed at 240 nm. Nevirapine retention time was 2 min. The method was validated over 0.1-10 microg/ml and the assay was linear over this concentration range (r2>0.998). Within- and between-day precisions were less than 5.4%. The lower limit of quantification was 0.1 microg/ml. Nevirapine in human serum samples was stable for 2 days at 20-25 degrees C, 15 days at 4 degrees C and 3 months at -20 degrees C.

[Information program applied to the temporal study of pathological processes in animal populations]

WinEpi Tasas 2.0 is a new, globally accessible computer program, which has been developed as a research tool for the epidemiological study of the pathological processes which affect animal populations. This new version of the program, based on the experimental version, WinEpi Tasas 1.0, enables users to study the distribution and evolution of diseases in affected populations, over time. This information, combined with data on spatial distribution, is of fundamental importance for the establishment of appropriate control strategies and health policies. Such disease control measures are of particular significance in the current context of emerging and re-emerging diseases. The program can be run in either English or Spanish.

(alphaMe)Nva: stereoselective syntheses and preferred conformations of selected model peptides

Using different stereoselective chemical and chemoenzymatic approaches we synthesized the chiral, Calpha-methylated alpha-amino acid L-(alphaMe)Nva with a short, linear side-chain. A set of terminally protected model peptides to the pentamer level containing either (alphaMe)Nva or Nva in combination with Ala and/or Aib was prepared using solution methods and characterized fully. Two (alphaMe)Nva peptides were also synthesized using side-chain hydrogenation of the corresponding Calpha-methyl, Calpha-allylglycine (Mag) peptides. A detailed solution and crystal-state conformational analysis based on FT-IR absorption, 1H NMR and X-ray diffraction techniques allowed us to define that: (i) (alphaMe)Nva is an effective beta-turn and 3(10)-helix former; and (ii) the relationship between (alphaMe)Nva chirality and the screw sense of the turn/helix formed is that typical of protein amino acids, i.e. L-(alphaMe)Nva induces the preferential formation of right-handed folded structures. In more general terms, this study reinforced previous conclusions that peptides based on alpha-amino acids with a Calpha-methyl substituent and a Calpha-linear alkyl substituent are characterized by a strong tendency to fold into turn and helical structures.

Comparison of immunologic restoration and virologic response in plasma, tonsillar tissue, and cerebrospinal fluid in HIV-1-infected patients treated with double versus triple antiretroviral therapy in very early stages: The Spanish EARTH-2 Study. Early Anti-Retroviral Therapy Study

The objective of antiretroviral therapy is to obtain an almost complete and durable suppression of viral replication in all compartments to facilitate recovery of the immune system. We assessed the virologic effect in plasma, tonsillar tissue, and cerebrospinal fluid (CSF) in 94 HIV-1-infected patients with CD4 counts >500 x 106 cells per liter and viral load >5000 copies/ml randomly assigned to triple antiretroviral therapy (two nucleoside reverse transcriptase inhibitors (NRTIs) plus one protease inhibitor) versus double therapy (two NRTIs). We also analyzed the immunologic recovery in this cohort of patients. Lymphoid tissue and cerebrospinal fluid viral load, development of genotypic resistance, proliferative responses to HIV-1 specific antigens, and other immunophenotypic markers were analyzed. The proportion of patients who achieved a decrease in HIV RNA levels to <200 copies/ml was significantly greater in the triple therapy group than in the two drug groups (p =.0002 for each pair-wise difference). At week 52, tonsillar tissue HIV RNA from 5 patients treated with triple therapy was lower than the limit of detection, whereas the mean +/- standard error in patients with double therapy (n = 5) was 5.03 +/- 0.34 copies/mg/tissue. In all 10 patients, CSF viral load (VL) was <20 HIV-1 RNA copies/ml at week 52. CSF cell counts and protein levels tended to decrease after 52 weeks of antiretroviral therapy. After 1 year of therapy, 13 of 21 patients (62%) in the double-therapy groups (zidovudine plus lamivudine [n = 9] and stavudine plus lamivudine [n = 12]) had evidence of M184V mutation. None of the 10 samples of patients receiving triple therapy could be amplified because of low HIV RNA levels. The mean increase in CD4 cells at week 52 was greater in the stavudine and lamivudine and indinavir group than in the double-treatment arms (186 versus 67 and 102, respectively; p =.03). In patients treated with triple therapy, the increase in naive T cells (CD4 and CD8) was greater than in patients treated with double therapy. Markers of activation decreased further in patients treated with the regimen that included protease inhibitors. Proliferative responses to HIV-1 p24 antigen were never recovered after double or triple therapy. Our study suggests that even in very early stages of HIV-1 disease only therapy with two NRTIs and one protease inhibitor reduces plasma, lymphoid tissue, and CSF VL to undetectable levels. HIV-1-related immune system abnormalities improved but were still defective after 1 year of antiretroviral therapy.

[Epidemiology of leptospirosis in a livestock production area of the Andes]

A cross-sectional study was conducted to estimate the prevalence of Leptospira infection in populations of workers, cattle, and pigs in livestock operations and to explore some environmental and production system variables associated with seropositivity. The research was done between November 1997 and February 1998 in the municipality of Don Matías, in the northern part of the department of Antioquia, Colombia. The area has a cold climate, and there is a "pigs-grasses-milk" production system that utilizes pig dung to fertilize grazing pastures. A total of 23 farms were studied, and blood samples were obtained from 67 dairy and pig-raising workers, 174 dairy cows, 68 pigs for fattening, and 214 pigs for breeding. The microagglutination test (MAT) was used for six Leptospira serotypes. The seropositivity prevalence was 22.4% among the workers (95% confidence interval: 13.1% to 34.2%), 60.9% among the dairy cows (95% CI: 53.2% to 68.2%), 10.3% in the fattening pigs, and 25.7% in the breeding pigs. Four logistic regression models were constructed to identify the variables that predicted infection in the workers and in the dairy cows. A high prevalence of infection with Leptospira (serotypes pomona, bratislava, and hardjo) was found in this production system, where conditions are favorable for transmitting this microorganism to the different animal species and to humans.

New antiherpetic 1,3-phenylene derivatives, inhibitors of the interaction of the HSV-1 origin binding protein (OBP) with DNA

The synthesis of new 1,3-phenylene derivatives and their preliminary evaluation as antivirals (Herpes simplex 1, HSV-1) whose antiherpetic activity can be related with the inhibition of the interaction of the origin binding protein (OBP) with the DNA are presented. The new compounds are adjusted to a previously defined common structural model, consisting of a central aromatic system, which presents two side chains of different lengths in relative position 1, 3; these chains are made up of atomic groups characterized by the alternation of positive and negative centers, situating differently substituted rings, preferably aromatic, at the ends of both chains. Some of these derivatives, such as N,N''-(4-methoxy-1,3-phenylene)bis[N'-(4-nitrophenyl)urea] (2c) or (1,3-phenylene)bis[N-(p-tolyl)aminosulfonyl] (11b), show antiherpetic activity related to the proposed mechanism.

Comparison of high and low doses of trimethoprim-sulfamethoxazole for primary prevention of toxoplasmic encephalitis in human immunodeficiency virus-infected patients

To evaluate the influence of the dose of co-trimoxazole prophylaxis on the risk of toxoplasmosis in human immunodeficiency virus (HIV)-infected patients, we performed a nested case-control study of 32 patients with toxoplasmosis (case patients) and 64 patients without toxoplasmosis (control patients) who were matched by CD4 cell count and Toxoplasma gondii serostatus; these patients were from a cohort of 521 HIV-infected patients who underwent a diagnostic neuroimaging study between March 1993 and January 1997. Twenty-seven (84.4%) of 32 case patients and 33 (51.6%) of 64 control patients received low doses of co-trimoxazole, a finding associated with an adjusted odds ratio (OR) of 9.36 (95% confidence interval [CI], 2.05-42.75) and indicating 89% protective efficacy for high doses. Fifteen (46.9%) of 32 case patients and 16 (25%) of 64 control patients were exposed to rifampin (adjusted OR, 3.38; 95% CI, 1.08-10.61). These results indicate that high doses of co-trimoxazole appear to be more effective than low doses for lowering the risk of toxoplasmosis in HIV-infected patients and that rifampin therapy may reduce the efficacy of co-trimoxazole.

[AIDS-free time and survival of an injecting drug users HIV seroconvertors cohort]

OBJECTIVE

To analyze AIDS free time, survival and the pre-AIDS survival for a injecting drug users cohort (IDU) of HIV seroconvertors.

SUBJECT AND METHODS

Interval for seroconversion was available for 276 IDUs from Centers for AIDS Information and Prevention (CIPS) recruited between 1987 and until June of 1996. AIDS diagnosis and vital status dates were obtained by follow up at hospitals, mortality and AIDS registries, and CIPS visits. The end of follow up was December of 1996. Seroconversion date was estimated as the middle point between last HIV- and first HIV+. Kaplan-Meier extension and Cox regression for truncated data were fitted to estimate AIDS-free and survival times and to observe differences by sex, age consumption time and year of seroconversion. Weibull, and Log-normal parametric models were fitted to estimate median and percentiles of AIDS-free and survival times distribution.

RESULTS

34 cases have been identified as AIDS, 24 as deaths, 9 of them being before AIDS. 63.5% of the individuals were AIDS-free 7 years after seroconversion, and the probability of death was 25.50. Pre-AIDS mortality is around 8.7%. There were not significant differences by sex, age, consumption time and year of seroconversion. Log-normal model fitted better estimating an AIDS-free median time of 10.93 years and 13.67 survival years.

CONCLUSION

The incubation period of HIV infection in a cohort of seroconvertors in our environment was around 11 years, not different from that observed out of the Mediterranean area as Holland, Scotland or United States

Family interventions in schizophrenia: an analysis of non-adherence

OBJECTIVE

The aim of this study was to identify baseline factors which may make it possible to predict non-adherence to prescribed treatment.

METHOD

A total of 87 schizophrenic patients in a catchment area of Valencia (Spain) were randomly assigned to two family strategies. The characteristics associated with lack of adherence to the programmes were analysed in both the patients and their families.

RESULTS

Older patients, those with a higher number of previous hospital admissions, those living in small households and those having relatives with little knowledge of schizophrenia at the time of the initial assessment were the main factors associated with a higher risk of dropping out of the interventions.

CONCLUSIONS

The findings of this study offer some guidance on suggesting intervention strategies that might reduce drop-out rates in these types of programmes.