Valproic acid in association with highly active antiretroviral therapy for reducing systemic HIV-1 reservoirs: results from a multicentre randomized clinical study

OBJECTIVES

Conflicting results have been reported regarding the ability of valproic acid (VPA) to reduce the size of HIV reservoirs in patients receiving suppressive highly active antiretroviral therapy (HAART). In a randomized multicentre, cross-over study, we assessed whether adding VPA to stable HAART could potentially reduce the size of the latent viral reservoir in CD4 T cells of chronically infected patients.

METHODS

A total of 56 virologically suppressed patients were randomly assigned either to receive VPA plus HAART for 16 weeks followed by HAART alone for 32 weeks (arm 1; n  = 27) or to receive HAART alone for 16 weeks and then VPA plus HAART for 32 weeks (arm 2; n  = 29). VPA was administered at a dose of 500  mg twice a day (bid) and was adjusted to the therapeutic range. A quantitative culture assay was used to assess HIV reservoirs in CD4 T cells at baseline and at weeks 16 and 48.

RESULTS

No significant reductions in the frequency of CD4 T cells harbouring replication-competent HIV after 16 and 32 weeks of VPA therapy were observed. In arm 1, median (range) values of IU per log(10) billion (IUPB) cells were 2.55 (range 1.20-4.20), 1.80 (range 1.0-4.70) and 2.70 (range 1.0-3.90; P = 0.87) for baseline, week 16 and week 48, respectively. In arm 2, median values of IUPB were 2.55 (range 1.20-4.65), 1.64 (range 1.0-3.94) and 2.51 (range 1.0-4.48; P = 0.50) for baseline, week 16 and week 48, respectively.

CONCLUSIONS

Our study demonstrates that adding VPA to stable HAART does not reduce the latent HIV reservoir in virally suppressed patients.

Prognostic value of post-thyroidectomy thyroglobulin levels in patients with differentiated thyroid cancer

BACKGROUND

Thyroglobulin is an excellent biological marker of persistent or recurrent thyroid cancer during long-term follow-up. Most studies investigated its diagnostic value but not its prognostic value over time. We aim to study the prognostic value of thyroglobulin levels early after total thyroidectomy, before iodine ablation.

METHODS

The study was based on the Rabin Medical Center registry of patients with non-medullary thyroid carcinoma. Data were collected on the clinical, laboratory, and outcome characteristics of 420 consecutive patients followed at our institution for whom early post-operative pre-ablation thyroglobulin values (baseline thyroglobulin) were available.

RESULTS

Patients were classified into 4 groups by baseline thyroglobulin level: 0-2, 2-10, 10-100, and >100 ng/ml. Higher levels were associated with a shift toward male gender (p=0.01), larger tumor size (p=0.02), and a more extensive disease (p<0.0001). They were also related to disease persistence and evidence of disease at last follow-up (p<0.0001). The 10 ng/ml cut-off level identified patients with persistent disease with a sensitivity and specificity of 73%, positive predictive value of 43%, and negative predictive value of 89%. On multivariate analysis, the following variables were predictive of persistent disease: baseline thyroglobulin level, male gender, lymph-node involvement, distant metastases, higher tumor invasiveness, and larger tumor size. However, the predictive power of baseline thyroglobulin level was relatively weak (odds ratio 1.002, 95% confidence interval 1.00-1.04).

CONCLUSIONS

In patients with well-differentiated thyroid cancer, a post-thyroidectomy thyroglobulin level <10 ng/ml is associated with a low probability of having persistent disease and can be used combined with other disease characteristics for decisions regarding treatment and follow-up.

The association of magnetic resonance imaging (MRI)-detected structural pathology of the knee with crepitus in a population-based cohort with knee pain: the MoDEKO study

Osteoarthritis (OA) is the most common arthropathy of the knee joint(1). Symptoms reported by patients and signs noted during physical examination guide clinicians in identifying subjects with knee OA(2-4). Pain is one of the most important symptoms reported by subjects with knee OA(2,3). Although very common, pain is a non-specific symptom, related to pathology in several structures within the knee joint, and includes synovitis(5), subchondral bone marrow lesions(6), and joint effusion(7). Further, pain is a subjective symptom that cannot be directly measured or assessed during physical examination. Crepitus or crepitation in association with arthritis is defined as a crackling or grinding sound on joint movement with a sensation in the joint. Crepitus may occur with or without pain and is a common finding during physical examination in subjects with knee OA(2-4,8,9). It is not known whether crepitus is related to pathology in various structures within the knee. The aim of our study was to determine the cross-sectional associations of structural pathologies within the knee with crepitus in a population-based cohort with knee pain, using magnetic resonance imaging (MRI). Subjects with knee pain were recruited as a random population sample, with crepitus assessed in each compartment of the knee using a validated and standardized approach during physical examination(10). MRI of the knee was performed to assess cartilage morphology, meniscal morphology, osteophytes, cruciate ligaments, and collateral ligaments. For both compartment-specific and whole-knee analyses, a multiple logistic regression analysis was performed to assess the associations of MRI-detected structural pathology with crepitus, adjusting for potential confounders. Variables were selected by backwards elimination within each compartment and in the overall knee models, and only statistically significant variables remained in the "selected" models; remaining variables in these models are adjusted for each other. An increased risk for compartment-specific crepitus was associated with osteophytes at the patellofemoral (PF) and lateral tibiofemoral (LTF) joints. Crepitus was associated with osteophytes and medial collateral ligament (MCL) pathology at the medial tibiofemoral (MTF) compartment, but cartilage damage was negatively associated with crepitus at this compartment. In the selected whole-knee model, only meniscal tears were associated with an increased risk for general crepitus. Thus, it seems that crepitus may be associated with pathology in several internal structures.

Natural history of cartilage damage and osteoarthritis progression on magnetic resonance imaging in a population-based cohort with knee pain

OBJECTIVES

To determine the natural history of cartilage damage and of osteoarthritis (OA) progression using magnetic resonance imaging (MRI); to evaluate whether OA progression varies by stage of disease.

METHODS

A population-based cohort with knee pain was assessed clinically, with X-ray (Kellgren-Lawrence [KL] grading) and MRI. Cartilage was graded 0-3 on six joint surfaces. Frequency of cartilage damage change was determined for each joint site. Progression of OA was defined as a worsening of MRI cartilage damage by ≥1 grade in at least two joint sites or ≥2 grades in at least one joint site. The association of KL grade with OA progression was evaluated using parametric lifetime regression analysis.

RESULTS

163 subjects were assessed at baseline and follow-up (mean 3.2 years). KL grade ≥2 was present in 39.4% at baseline. An increase in cartilage damage by ≥1 grade was seen in 8.0-14.1% of subjects at different joint sites. OA progression on MRI was present in 15.5%. Baseline KL grade was a significant predictor of OA progression with hazard ratio (HR) of 6.5 (95% confidence interval [CI] 1.4-30.7), 6.1 (95% CI 1.3-28.9), and 9.2 (95% CI 1.9-44.9) for KL grades 1, 2 and ≥3, respectively.

CONCLUSION

A low OA progression rate was seen over 3 years in this population-based symptomatic cohort. Radiographic severity, including KL grade 1, was a significant predictor of OA progression. Future interventions aimed at reducing progression will need to target not only radiographic OA, but also those with early abnormalities suggestive of pre-radiographic OA.

Evidence for a more pronounced effect of genetic predisposition than environmental factors on goitrogenesis by a case control study in an area with low normal iodine supply

Family and twin studies suggest a genetic predisposition for euthyroid goiters. However, iodine deficiency and smoking are important exogenous factors for goiter development. We investigated goiter predisposition by a matched case control study in a region with recently documented low normal iodine supply. A sum of 376 patients were included in the study. We matched 188 patients with euthyroid/subclinically hyperthyroid goiter (TSH 4.20-0.05 mU/l) with 188 euthyroid controls without thyroid enlargement for age and gender. Thyroid ultrasound was performed in all patients, whereby 50.5% of patients with goiters showed a positive family history for goiter. In contrast, only 25% of control patients had a positive family history (p<0.001; OR=3.1). Patients with goiters had a significantly higher proportion of parents (p<0.001; OR=3.6) or siblings (p=0.004; OR=2.5) with goiters. Children of parents with goiters showed a 2.7-fold increased risk for goiter development (goiter prevalence 73.3%). Patients with a positive goiter family history had a 4.1-fold increased goiter risk (p<0.001). The contribution of smoking, obesity, and pregnancies to goiter development was less important than the genetic predisposition (OR=1.7; p=0.06; OR=1.67; p=0.13; OR=0.8; p=0.56). In a region with low normal iodine supply, the significantly higher rate of positive family histories in patients with goiters as compared to the matched controls as well as the increased goiter prevalence in children of parents with goiters indicate the importance of genetic factors in goiter development.

Increased gallium-68 DOTATOC uptake in normal thyroid glands

Increased Ga-68 DOTATOC uptake for normal and goitrous and/or nodular thyroids has previously been reported for a small number of patients. The aim of this study was to reevaluate these preliminary findings with larger patient numbers and to determine possible variables, which might influence the quantification of Ga-68 DOTATOC uptake in normal and pathologic thyroid tissues. Ga-68 DOTATOC PET scans of 165 patients classified for various thyroid pathologies were analyzed by the so-called region of interest technique for Ga-68 DOTATOC uptake and the patient's history, thyroid ultrasound, TSH, and anti-TPO antibodies. Thyroid glands without any pathology showed a clearly detectable uptake of Ga-68 DOTATOC with a large variability and significantly higher target to background ratios for men as compared to women. In 8 cases of normal thyroids with an increased uptake, follow-up examinations after 6-14 months did not show any thyroid pathology. An increased DOTATOC uptake (target to background ratio >3.4) was found in hot nodules, disseminated thyroid autonomy, and in most cases (5 of 8) of active Hashimoto's disease. In Ga-68 DOTATOC PET, normal thyroid glands show a clearly detectable radiotracer uptake with a large variability and significantly higher target to background ratios in male patients. All patients with thyroid autonomy and most patients with active Hashimoto's disease have an increased thyroid DOTATOC uptake.

Clinical and economic impact of a specialty care management program among patients with multiple sclerosis: a cohort study

Background: To evaluate the clinical and economic impact of a specialty care management program among patients with multiple sclerosis.

Methods: This retrospective cohort analysis included patients aged ≥18 years with ≥2 claims of multiple sclerosis diagnosis and ≥1 multiple sclerosis medications from 1 January 2004 to 30 April 2008. The outcome metrics included medication adherence and persistence, multiple sclerosis-related hospitalization, and multiple sclerosis-related cost. Multivariate analyses were performed to adjust for demographics and clinical characteristics.

Results: Among the 3993 patients identified, 78.3% participated in the program and 21.7% did not. Over 12 months, medication adherence and persistence improved among participants but deteriorated among non-participants (medication possession ratio change: +0.08 vs −0.03, p < 0.001; persistence change: +29.2 days vs −9.2 days, p < 0.001). Multiple sclerosis-related hospitalization decreased from 9.6% to 7.1% for participants, whereas it increased from 10.1% to 12.0% for the non-participant group (p < 0.001). Multiple sclerosis-related medical spending (non-pharmacy) decreased among participants, but it increased among non-participants (mean: −US$264 vs + US$1536, p < 0.001). Total multiple sclerosis-related cost for both groups increased over time (+US$4471 vs +US$4087, p < 0.001).

Conclusions: This program was associated with improved medication adherence and persistence, reduced multiple sclerosis-related hospitalization, and decreased multiple sclerosis-related medical costs. Unfortunately, the cost savings in the medical component did not offset the increased pharmacy expenditures during the 12-month follow-up period.

Ectopic Cushing's syndrome caused by a well differentiated ACTH-secreting neuroendocrine carcinoma of the ileum

Cushing's syndrome can be caused by adrenocorticotropic hormone-secreting solid tumors. We report a rare case of an ileal endocrine carcinoma that produced ACTH and induced hypercortisolism. A now 47-year-old man presented at age 41 with weight gain, tremor, perspiration, and general fatigue. Laboratory testing showed hypercortisolism and diabetes mellitus. Further examinations revealed ectopic Cushing's syndrome. The search for the primary tumor was difficult. The patient underwent subtotal thyroidectomy and surgical removal of a pituitary lesion. After resection of an ACTH-producing metastasis of the mesentery, temporary remission of Cushing's syndrome ensued. At the age 45 the primary tumor was detected in the ileum by Ga-68 DOTATOC-PET scan and explorative laparotomy. After surgical removal of this well differentiated neuroendocrine carcinoma the patient significantly improved clinically. He experienced better blood pressure and remission of his diabetes mellitus in addition to increased muscular strength. Endocrine laboratory testing at follow-up examinations confirmed remission of hypercortisolism and diabetes mellitus. A Ga-68 DOTATOC PET scan and a 1 mg dexamethasone suppression test 5 months after surgery showed normal results. Ectopic ACTH secretion within the small bowel is very rare. This case underscores the difficulty in locating the source of ectopic ACTH secretion and suggests using small bowel barium study, tubus endoscopy or video endoscopy for preoperative localization if the small bowel is suspected as tumor source.