Hepatitis C virus coinfection and the risk of cardiovascular disease among HIV-infected patients

BACKGROUND

Among HIV-infected patients, hepatitis C virus (HCV) coinfection is associated with lower cholesterol levels, but it remains unclear how it affects cardiovascular outcomes.

METHODS

We performed logistic regression to evaluate acute myocardial infarction (AMI) and cerebrovascular disease (CVD) events by HCV status among HIV-infected US veterans in the highly active antiretroviral therapy (HAART) era (1996-2004). We then performed survival analyses to evaluate incident AMI and CVD, exploring antiretroviral therapy (ART) as a time-dependent variable.

RESULTS

A total of 19 424 HIV-infected patients [31.6% of whom were HCV-coinfected (HIV/HCV)] contributed 76 376 patient-years of follow-up. HCV coinfection was associated with lower rates of hypercholesterolaemia (18.0% in HIV/HCV vs. 30.7% in HIV-only patients; P<0.001), but higher rates of hypertension (43.8%vs. 35.6%; P<0.0001), type 2 diabetes mellitus (16.2%vs. 11.1%; P<0.0001) and smoking (36.7%vs. 24.7%; P=0.009). Rates of AMI and CVD were significantly higher among HIV/HCV than HIV-only patients: 4.19 vs. 3.36 events/1000 patient-years, respectively (P<0.001), for AMI; and 12.47 vs. 11.12 events/1000 patient-years, respectively (P<0.001), for CVD. When analyses were controlled for diabetes mellitus, hypertension, age and duration of ART, hazard ratios (HRs) among those with HIV/HCV (vs. HIV only) were 1.25 [95% confidence interval (CI) 0.98-1.61; P=0.072] for AMI and 1.20 (CI 1.04-1.38; P=0.013) for CVD. Hypertension (HR 2.05; P<0.001), greater age (HR 1.79; P<0.001) and longer duration (cumulative years) of antiretroviral use (HR 1.12; P=0.0411) were also associated with increased risk of AMI in the adjusted model.

CONCLUSIONS

In the HAART era, HCV coinfection was associated with a significantly increased risk of CVD and a trend towards an increased risk of AMI among HIV-infected patients.

Meticillin-resistant Staphylococcus aureus hepatic abscess treated with tigecycline

Pyogenic liver abscesses are uncommon in clinical practice and are usually polymicrobial in nature, with members of the Enterobacteriacae family often implicated. This report describes the use of tigecycline to treat a liver abscess caused by methicillin-resistant Staphylococcus aureus, which was refractory to therapy with standard antimicrobials.

Detection and biovar discrimination of Ureaplasma urealyticum in Indian patients with genital tract infections

Prevalence of the 2 ureaplasma biovars was estimated in patients with genital tract infections by polymerase chain reaction targeting the urease and multiple-banded antigen gene. Ureaplasma was more frequently isolated in symptomatic than asymptomatic subjects (48% versus 22%) (P=0.001). Biovar 1 was predominant; however, there was no difference in the distribution of the 2 biovars between the symptomatic and asymptomatic subjects.

Inhibition of apoptosis, activation of NKT cell and upregulation of CD40 and CD40L mediated by M. leprae antigen(s) combined with Murabutide and Trat peptide in leprosy patients

Protective immunity against intracellular pathogen Mycobacterium leprae is dependent on the activation of T cells. Repeated stimulation of T cells by M. leprae antigens MLCwA (M. leprae total cell wall antigen) and ManLAM (mannose-capped lipoarabinomannan), may lead to apoptosis in leprosy patients. In the present study, inhibition of the Fas-induced apoptosis of peripheral blood mononuclear cells of leprosy patients was investigated using above M. leprae antigen(s), in combination with immunomodulators murabutide (MB) and a Trat peptide in particulate form (liposome). Incubation of the cells with antigen containing the two immunomodulators in particulate form (liposomes) led to decrease in percentage of propidium iodide positive cells and T cells expressing Fas-FasL as well as decreased caspase-8/-3 activities in lepromatous patients, thereby inhibiting apoptosis, while converse was true upon stimulation with soluble antigen. Concurrently, there was an upregulation of antiapoptotic protein Bcl-xL in lepromatous patients, leading to the inhibition of apoptosis. It was also observed that same formulation upregulated the expression of CD40 on B cells and monocytes-macrophages and CD40L on T cells of lepromatous leprosy patients. The same liposomal formulation significantly increased the expression of CD1b and CD1d on monocytes-macrophages as well as percentage of NKT cells secreting IFN-gamma in lepromatous leprosy patients. Thus, the liposomal formulation of antigen with the immunomodulators in vitro promoted the activation of CD40:CD40L pathways and NKT cell function involved in providing cell-mediated immunity to these patients. The same formulation also caused reversal of T cell anergy by inhibiting apoptosis through decreased expression of death receptors (Fas-FasL) and caspase activities (3 and 8) and increased expression of antiapoptotic protein Bcl-xL in these patients.

Liposomal delivery of Mycobacterium leprae antigen(s) with murabutide and Trat peptide inhibits Fas-mediated apoptosis of peripheral blood mononuclear cells derived from leprosy patients

Protective immunity against intracellular pathogen Mycobacterium leprae is dependent on the activation of T cells. Repeated stimulation of T cells by M. leprae antigens MLCwA (M. leprae total cell wall antigen) and ManLAM (mannose capped lipoarabinomannan) may lead to apoptosis in leprosy patients. In the present study, inhibition of the Fas-induced apoptosis of peripheral blood mononuclear cells of leprosy patients was investigated using above M. leprae antigen(s), in combination with immunomodulators murabutide (MB) and a Trat peptide in particulate form (liposome). Incubation of the cells with particulate mode of antigen presentation led to both decreased percentage of propidium iodide (PI) positive cells and T cells expressing Fas-FasL, as well as decreased caspase-8/-3 activities in the lepromatous patients, thereby inhibiting apoptosis, while converse was true with stimulation with soluble antigen. Concurrently, there was an upregulation of antiapoptotic protein Bcl-X(L) in the lepromatous patients, thereby inhibiting apoptosis. Thus, the liposomal formulation of antigen promoted proliferation of anergized T cell by inhibiting apoptosis through decreased expression of death receptors and caspase activities and increased expression of anti-apoptotic protein Bcl-X(L) in these patients.

Single antigen detects both immunoglobulin M (IgM) and IgG antibodies elicited by all four dengue virus serotypes

The resurgence of dengue (DEN) virus infections in the last few decades coupled with the lack of a preventive vaccine and specific antiviral drugs has jointly contributed to making this a significant global public health problem. Currently, symptomatic supportive treatment and fluid replacement therapy are the only means available to minimize DEN-induced mortality. As the clinical symptoms associated with DEN virus infections are indistinguishable from those of many other viral, bacterial, and parasitic infections, specific diagnostic tests assume critical importance in the unequivocal identification of DEN virus infections. We have designed a novel chimeric antigen based on envelope domain III (EDIII), a critical antigenic region of the major structural protein of DEN viruses. We fused EDIIIs corresponding to each of the four DEN virus serotypes using pentaglycyl linkers, overexpressed the resultant tetravalent chimeric protein in Escherichia coli, and affinity purified it in high yields, obtaining approximately 30 mg protein of >95% purity per liter of culture. We show that this tetravalent antigen could specifically recognize anti-DEN virus antibodies of both the immunoglobulin M (IgM) and IgG classes. Using a large panel of IgM antibody capture-enzyme-linked immunosorbent assay- and hemagglutination inhibition-confirmed DEN virus-infected and uninfected patient sera (n = 289), we demonstrate that this tetravalent antigen can function as a diagnostic tool of high sensitivity and specificity.

Peripheral blood culture contamination in adults and venepuncture technique: prospective cohort study

Aims:

To test the hypothesis that compliance with a hospital protocol on peripheral blood culture (PBC) collection in adults is associated with a reduction in PBC contamination, and to investigate likely contributing factors for contamination.

Methods:

A prospective cohort study was conducted, utilising data collection by participant questionnaire completion, and utilising bacteriology laboratory results on PBCs. Participants were all healthcare workers involved in obtaining PBCs from adults.

Results:

1460 PBCs with questionnaires were received. Contamination among the 1460 PBCs as a whole was 8.8%. 766 of the questionnaires were sufficiently complete to allow analysis of blood culture contamination in relation to protocol compliance. Among these, protocol compliance was 30% and contamination was 8.0%. When the protocol was complied with, 2.6% of PBCs were contaminated, but when the protocol was not followed, contamination was significantly higher at 10.3% (OR 4.35, 95% CI 1.84 to 12.54). Univariate analysis on all 1460 PBCs suggested that the site for blood collection, and disinfection of the venepuncture site were important factors in PBC contamination: when no venepuncture site disinfection was performed, contamination was significantly higher than when alcohol was used (5.1% versus 15.8%, OR 3.46, 95% CI 2.01 to 5.97); when a PBC collection site other than a fresh peripheral vein was used, contamination was significantly higher (7.3% versus 12.0%, OR 1.75, 95% CI 1.03 to 2.96).

Conclusions:

Compliance with a hospital protocol on PBC collection technique in adults significantly reduces blood culture contamination.

Human papillomavirus detection in self-collected vaginal specimens and matched clinician-collected cervical specimens

Human papillomavirus (HPV) detection is an integral part of cervical cancer screening, and a range of specimen collection procedures are being tested. Preliminary studies have found that the majority of women prefer self-collection of vaginal specimens instead of clinician-collected specimens of the cervix. The purposes of the current study were to explore the social and behavioral predictors of acceptance of self-collection of vaginal specimens among patients and to assess concordance in detection of HPV between clinician-collected cervical specimens and self-collected vaginal specimens. The study was conducted at a university family medicine clinic using a cross-sectional study design, and enrollment of women presenting for routine gynecological examination consecutively in a period of 1 year, self-administered questionnaires, collection of paired vaginal and cervical specimens for HPV DNA using Hybrid Capture 2, and cytologic analysis. Most women (79.8% [398/499]) agreed to collect vaginal specimens. In our study, 76.6% (216/282) African American women (AA), 88.1% (156/176) white non-Hispanic (WNH) women, and 63.4% (26/41) women of other races (P < 0.0001) agreed to self-collect vaginal specimens. HPV was detected in 16.0% (80/499) of clinician-collected cervical specimens and 26.1% (104/398) of self-collected vaginal specimens (P < 0.001). HPV detection was concordant in 13.4% (53/398) women in both cervical and vaginal specimens. Self-collection of vaginal specimens for HPV DNA detection is acceptable to most women presenting for routine gynecological examination. WNH women were more likely to obtain self-collected specimens than AA women. Vaginal specimens were more likely to be positive for HPV than were cervical specimens.

Alterations in T cell signal transduction by M. leprae antigens is associated with downregulation of second messengers PKC, calcium, calcineurin, MAPK and various transcription factors in leprosy patients

Mycobacterium leprae, the causative agent of leprosy, challenges host defense mechanism by impairing the signal transduction of T cells which leads to downregulation of T cell proliferation, mainly as a consequence of interference with IL-2 production. In this study we sought to identify how soluble forms of M. leprae antigen(s) or particulate (liposome) delivery of the same antigens with two immunomodulators Murabutide and T cell peptide of Trat protein influence the transcription of IL-2 gene in anergic T cells of lepromatous patients. It was demonstrated that MLCwA/ManLAM stimulated cells of BL/LL patients showed defects in both jun-NH2-terminal kinase (JNK) and extracellular signal-regulated kinase (ERK) activities there by resulting in decreased AP-1 activity. Additionally these cells showed reduced calcium levels, PKC activity and calcineurin (CN) activity. This led to impaired nuclear translocation of NFkappaB and NFAT in these patients. In contrast, when same M. leprae antigen(s) were incorporated with the two immunomodulators in liposomal form, increased transcription of IL-2 gene was observed especially in BL/LL patients which appears to be due to, at least in part, to increased expression of AP-1 Fos and Jun family members, NFkappaB and NFAT1 proteins. The increased expression of these transcription factors correlated with increased ERK/JNK, PKC and CN activities in these patients. Since activation of ERK/JNK/PKC kinases and CN phosphatase are required for stimulation of IL-2 transcription, these data provide a molecular explanation for the block in IL-2 production by M. leprae antigens. Thus the above study revealed suppression of all the three distinct biochemical pathways, viz. Ca-CN-NFAT pathway, PKC-NF-kappaB pathway, and MAPK-AP-1 pathway by M. leprae antigen(s) in anergized T cells of lepromatous patients which were activated by liposomal delivery of M. leprae antigens containing the two immunomodulators leading to optimal induction of IL-2 gene expression, which was required for the activation, and proliferation of T cells in lepromatous patients.

Hearing loss after discontinuing secondary prophylaxis for cryptococcal meningitis: relapse or immune reconstitution?

Relapse and immune reconstitution syndrome are difficult to distinguish in HIV-infected patients treated with antiretroviral therapy (ART). We report on a 26-year-old HIV-infected male (CDC C3) with hearing loss on the right side 2 months after discontinuing secondary prophylaxis for cryptococcal meningitis. CD4 cell counts had increased from 32/microl to stable counts > 200/microl for the preceding 6 months on ART but HIV replication was not fully suppressed (7,000 copies/ml). Magnetic resonance imaging identified lesions at the origin of the right cranial nerve VIII. Lumbar puncture revealed monocytic pleocytosis, slightly increased protein, but normal glucose and lactate levels, negative microbiological studies. Fluconazole was restarted and a new ART regimen was started in order to fully suppress HIV replication. Clinical and radiological signs were reversible during follow-up, and secondary prophylaxis was stopped after 6 months without adverse events. We review 26 published cases of cryptococcal infections with immune reconstitution syndrome and highlight the distinguishing features.

Evaluation of a new fixed duration (12 weeks) multi-drug regimen of bactericidal drugs in multibacillary leprosy

Leprosy still remains a public health problem mainly in Asia, Africa and South America. The WHO Expert Committee on Leprosy recommended, in 1997, the simplified treatment of leprosy for multibacillary (MB) cases, by reducing the duration of treatment from 24 to 12 months. From the operational point of view even this reduced duration is still long and monthly supervised drug administration may not always be practical in those areas where the accessibility is difficult and health infrastructure weak. The present study was carried out to compare the safety and efficacy of a new fixed duration regimen consisting of four bactericidal drugs with WHO/MDT (MB).

METHODS

Thirty adult patients were randomly allocated to two groups. Group 1 (18 patients) received a new regimen of daily rifampicin 600 mg, sparfloxacin 200 mg, clarithromycin 500 mg and minocycline 100 mg for 12 weeks. Group 2 (12 patients) received WHO/MDT (MB) for 12 months. A detailed clinical evaluation and laboratory investigations, BI and MI were done at the baseline, every 4 weeks for 12 weeks, and thereafter every 8 weeks till 48 weeks. Skin biopsies were taken and chest X-rays were done at 0, 12 and 48 weeks.

RESULTS

At 48 weeks, the net percentage clinical improvement in group 1 was 73.92% and in group 2 it was 66.66%. The net percentage reduction (NPR) in BI in group 1 was 19.17% and in group 2 it was 18.87% (p = 0.09). NPR in MI in both groups was 100% by 8 weeks, and somewhat faster in group 1. In group 1, 8 patients had mild gastrointestinal side-effect, and 16 had minocycline-induced hyperpigmentation. Three patients in group 1 developed type I reversal reactions.

CONCLUSION

The regimen containing daily doses of rifampicin 600 mg, sparfloxacin 200 mg, minocycline 100 mg and clarithromycin 500 mg for 12 weeks was found to be an acceptable, effective and safe alternative regimen for MB leprosy with an additional operational advantage of shorter duration of treatment.

Melkersson-Rosenthal syndrome with diffuse facial swelling and multiple cranial nerve palsies

We report an unusual case of Melkersson-Rosenthal syndrome presenting as diffuse facial swelling with facial, glossopharyngeal and vagus nerve palsies. A skin biopsy revealed non-caseating epithelioid cell granulomas throughout the dermis. The disease responded poorly to systemic steroids, antihistamines, antibiotics and potassium iodide.

Evaluation of the diagnostic efficacy of PCR for Ureaplasma urealyticum infection in Indian adults with symptoms of genital discharge

Ureaplasma urealyticum genital infection may lead to severe clinical implications if left undiagnosed and untreated. The present study was conducted to evaluate the diagnostic efficiency of a polymerase chain reaction (PCR) assay and to determine the prevalence of U. urealyticum in Indian adults with symptoms of genital discharge. Cervical swabs, vaginal swabs and male urethral swabs from 100 patients attending an sexually transmitted disease clinic at a tertiary care hospital in Delhi were screened prospectively for infection with U. urealyticum. The prevalence of U. urealyticum was found to be 32% by culture and 45% by PCR. U. urealyticum was recovered from 8 (47%) and 37 (45%) symptomatic men and women, respectively. The agreement between PCR and culture was 93.75%. PCR improved the test sensitivity by 13% compared to culture. The results confirm the need to use a sensitive and reliable molecular method to prevent the underdiagnosis of ureaplasma infection and to facilitate better clinical management of this infection in India.

Dapsone-induced eosinophilic pneumonitis in a leprosy patient

A leprosy patient with no prior history of respiratory complaints, developed symptoms of dry cough, fever and dyspnea after six weeks of therapy. Peripheral eosinophilia and radiological evidence of pulmonary interstitial infiltrates pointed towards the possibility of drug-induced eosinophilic pneumonitis. The results of relevant tests for other possible pathologies were normal. The resolution of symptoms without any intervention other than withdrawal of the drug and subsequent re-challenge proved dapsone to be the cause.

Lesional T-cell subset in post-kala-azar dermal leishmaniasis

BACKGROUND

The pathogenesis of post-kala-azar dermal leishmaniasis (PKDL) is ill understood. This study was carried out to find the percentage of T-helper and T-suppressor cells in lesional tissue and their probable role in the pathogenesis of PKDL.

METHODS

An immunoperoxidase monoclonal antibody technique was used to characterize and quantify the subsets of T lymphocytes in the infiltrate in 25 patients with PKDL.

RESULTS

The ratio of T-helper to T-suppressor cells was 0.87 in hypopigmented macules and 0.85 in nodule and/or plaque lesions of PKDL.

CONCLUSIONS

In this study, there was a definite preponderance of T-suppressor cells over T-helper cells in both types of skin lesions of PKDL. Further studies should be undertaken on larger numbers of patients to compare T-cell subsets both in skin lesions and the circulation, in order to determine the pathogenesis of PKDL.

Post-kala-azar dermal leishmaniasis: A histopathological study

BACKGROUND

Post-kala-azar dermal leishmaniasis follows an attack of visceral leishmaniasis and is caused by the same organism, i.e. Leishmania donovani.

METHODS

In the present study, biopsy specimens from hypopigmented macules, nodules or plaques of 25 patients clinically diagnosed as PKDL were evaluated for epidermal and dermal changes and for the presence or absence of Leishmania donovani bodies (LDBs).

RESULTS

The hypopigmented macules showed a patchy perivascular and periappendageal infiltrate with no demonstrable LDBs in any of the biopsies. In the nodular and plaque lesions, the infiltrate was diffuse, beneath an atrophic epidermis (74%) and follicular plugging (95.6%) was seen in most biopsies. The infiltrate consisted of lymphocytes, histiocytes and plasma cells in decreasing order of presence. LDBs could be demonstrated in only 10 (43.5%) biopsy specimens from nodular and plaque lesions and were never numerous.

CONCLUSIONS

Histopathological features of PKDL are elucidated and discussed.

Cutaneous plasmablastic lymphoma in an HIV-positive male: an unrecognized cutaneous manifestation

Plasmablastic lymphoma (PBL) is a rare and relatively new entity originally described in HIV-infected individuals. This subset of Epstein-Barr-virus (EBV)-related non-Hodgkin lymphomas is now regarded as a distinct clinicopathological category of AIDS-associated lymphomas occurring preferentially in the oral cavity and showing a poor prognosis. We describe for the first time an EBV-associated PBL with an isolated cutaneous distribution on the lower extremities in an HIV-infected heterosexual male and point to the unique clinical, morphological and immunophenotypic characteristics of this lymphoma. The patient presented with fast growing solid and livid nodules on both legs. The large, blastic tumor cells showed the following immunophenotype: CD138+, CD45+, CD20-, CD10-, CD3-, CD30-, bcl-2-, bcl-6-, LMP-1- and EMA-. The proliferation fraction (Mib-1) was >90%. EBV association was demonstrated by in situ hybridization (EBV-encoded RNAs 1/2). Polymerase-chain-reaction-based DNA analysis demonstrated a clonal IgH rearrangement in the absence of a bcl-2/IgH translocation. PBL in HIV patients may occur not only in the oral cavity, but can probably involve any other organs including the skin.

Mucosal and peri-orificial involvement in post-kala-azar dermal leishmaniasis

BACKGROUND AND AIMS

Lesions of post-kala-azar dermal leishmaniasis (PKDL) usually affect the skin. Uncommonly, the involvement of oral and genital mucosae has been reported.

METHODS

Twenty five patients clinically diagnosed as post-kala-azar dermal leishmaniasis were studied for periorificial and mucosal lesions. Clinical examination, skin smears and biopsy were done for the patients with periorificial or mucosal lesions.

RESULTS

Out of 25 patients of PKDL, seven patients had lesions on the oral and/or genital mucosa. Three cases had oral lesions; two had only genital lesions and three patients had both sites involved. All the patients were having skin lesions elsewhere too either as nodules and/or plaque or macules.

CONCLUSION

While examining a case of PKDL, mucosal involvement must also be examined carefully.

Lipodystrophy following hepatitis infection: A causative relationship?

Progressive partial lipodystrophy is a clinical syndrome characterized by progressive loss of subcutaneous fat. A 27-year-old female developed progressive loss of fat from the face and upper part of the torso associated with increased bulkiness of the body below the pelvis following an attack of hepatitis. She had been persistently hepatitis B surface antigen positive and her serum was positive for IgG antibodies to hepatitis B core antigen. Although the woman had hypocomplementaemia of the C3 component of complement, there was no evidence of renal involvement.

Reversal of T cell anergy in leprosy patients: in vitro presentation with Mycobacterium leprae antigens using murabutide and Trat peptide in liposomal delivery

Mycobacterium leprae, the causative agent of leprosy resides and multiplies within the host monocytes and macrophages, thereby evading host immune system. Cell-mediated immune response (CMI) plays a vital role as evidenced from the high CMI in BT/TT (borderline and tuberculoid) patients and conversely low in BL/LL (borderline and lepromatous) patients. In the present study, an attempt was made to immunomodulate the anergized T cells of lepromatous leprosy patients by presenting the mycobacterial antigen in combination with T cell adjuvant, murabutide (active analog of muramyl' dipeptide, MDP-BE) and a Trat peptide (T cell epitope of Integral membrane protein (Trat) from Escherichia coli) in particulate form (liposomes) or soluble form (media). PBMNC of normal, BT/TT and BL/LL were stimulated in vitro with five mycobacterial antigens (Ag) in the following formulations, Ag, Ag+murabutide, Ag+murabutide+Trat peptide either in liposomes or in medium. All the five antigen(s) when delivered in liposomes containing murabutide and Trat peptide showed a very high lymphoproliferative response (p<0.001) in all the three groups. IFN-gamma and IL-2 were significantly (p<0.001) high in these culture supernatants compared to IL-10 and IL-4 confirming a shift from CD4+Th2 to Th1 response in leprosy patients with particulate mode of antigen presentation. Interestingly, PBMNC derived from lepromatous patients also showed consistent T cell proliferation with all the formulations. Further, the mechanism of liposomal processing of antigens was studied using different inhibitors that interfere at different stages of antigen presentation. Results indicate that this study may pave way for an immunotherapeutic approach for reverting the anergic T cells of lepromatous patients to proliferating T cells with the release of Th1 cytokines thereby restoring the CMI response in these patients.

Therapeutic trial of sodium antimony gluconate alone and in combination with ketoconazole in post-kala-azar dermal leishmaniasis

BACKGROUND

Drugs used in PKDL include parenteral sodium antimony gluconate (SAG), amphotericin-B, pentamidine, and ketoconazole (KTZ). SAG is the most effective one. Given alone, SAG has to be given for a long duration, leading to poor patient compliance and treatment failure. This study was carried out to compare the effectiveness of SAG alone and a combination of SAG and KTZ for sixty days.

METHODS

Ten patients of PKDL were included in the study. Five patients (Group A) were given SAG intravenously, in the dose of 20 mg/kg per day and five (Group B) were given SAG (intravenously 20 mg/kg per day) and KTZ (200 mg twice daily orally). Both treatment regimens were given for sixty days.

RESULTS

In Group A, the nodules and/or plaques showed approximate 80-85% clinical improvement, and macules showed 25-30% improvement. In group B (SAG + KTZ), there was 90-95% clinical improvement in the nodules and/or plaques and 25-30% in macules.

CONCLUSION

This study suggests the therapeutic superiority of the combination treatment regimen in a shorter duration but is not conclusive as the number of patients was low. Further trials are recommended.

Failures of 1 week on, 1 week off antiretroviral therapies in a randomized trial

BACKGROUND

Scheduled treatment interruptions are being evaluated in an effort to decrease costs and side effects of highly active antiretroviral therapy (HAART). A schedule of 1 week on and 1 week off therapy offers the promise of 50% less drug exposure with continuously undetectable HIV RNA concentration.

METHODS

In the Staccato study 600 patients on successful HAART were to be randomized to either continued therapy, CD4-guided therapy, or one week on, one week off therapy. A scheduled preliminary analysis evaluated effectiveness in the 1-week-on-1-week-off arm.

RESULTS

Of 36 evaluable patients, 19 (53%) had two successive HIV RNA concentrations > 500 copies/ml at the end of the week off therapy, and were classified as virological failure. Most of those who failed took didanosine, stavudine, saquinavir, and ritonavir (11 patients). In these patients, there was no evidence of mutations suggestive of drug resistance, and plasma saquinavir levels were within the expected range. Two of three patients failing on triple nucleotides had drug resistance mutations, but nonetheless responded to reintroduction of triple nucleotide therapy. One of two patients taking nevirapine, and one of eight taking efavirenz, also failed. Both had resistance mutations at the time of failure, but not at baseline.

CONCLUSIONS

The 1-week-on-1-week-off schedule, as tested in the Staccato study, showed an unacceptably high failure rate and was therefore terminated.

Gastroenteritis outbreak with norovirus in a Swiss university hospital with a newly identified virus strain

We report an outbreak of norovirus-associated gastroenteritis in patients and healthcare workers (HCWs) at a university hospital in Switzerland during the period from 28 February to 31 March 2001. Faecal and vomitus specimens and bottled and drinking water were investigated for norovirus by reverse transcriptase-polymerase chain reaction (RT-PCR) Sixty-three patients and HCWs were affected. 37% of the investigated stool specimens were positive for norovirus. Sequencing showed a new phylogenetic strain, "Basel". There was no evidence for a water-borne, foodborne or environmental source. The source of the outbreak was most likely a patient admitted to the hospital. Once an outbreak was suspected, measures were instituted based on published guidelines, such as isolation of patients and excluding sick HCWs from work. However, the application of the guidelines proved difficult. A first realistic goal in such situations is to limit spread of the disease to other areas, specifically to high-risk areas such as intensive care and haemato-oncology units. Optimal management includes a rapid diagnosis of norovirus, written recommendations for management of affected patients and HCWs, and cleaning of surfaces with an effective disinfectant. These recommendations should be available in written form well before such an outbreak is in progress. Such preparations may limit the extent of the outbreak, but norovirus infection in a hospital will probably spread despite infection control interventions.

Antinociceptive action of Ocimum sanctum (Tulsi) in mice: possible mechanisms involved

The alcoholic leaf extract of Ocimum sanctum (OS, Tulsi) was tested for analgesic activity in mice. In the glacial acetic acid (GAA)-induced writhing test, OS (50, 100 mg/kg, i.p.; and 50, 100, 200 mg/kg, p.o.) reduced the number of writhes. OS (50, 100 mg/kg, i.p.) also increased the tail withdrawal latency in mice. Naloxone (1 mg/kg, i.p.), an opioid antagonist, and DSP-4 (50 mg/kg, i.p.), a central noradrenaline depletor, attenuated the analgesic effect of OS in both the experimental models, whereas, PCPA (300 mg/kg, i.p.), a serotonin synthesis inhibitor, potentiated the action of OS on tail flick response in mice. The results of our study suggest that the analgesic action of OS is exerted both centrally as well as peripherally and involves an interplay between various neurotransmitter systems.

Lupoid sycosis of pubic area

Lupoid sycosis is a rare cicatricial form of chronic folliculitis commonly seen in men after puberty. It usually involves the beard area and is refractory to treatment. We here report two cases of lupoid sycosis; one had additional involvement of the pubic area. Both patients showed complete clearance with minocycline.

[Exacerbation of chronic hepatitis B after discontinuing of antiretroviral therapy in HIV infection]

Eine HIV-infizierte Patientin stellt sich mit Ikterus und erhöhten Leberwerten vor. Als Ursache wird eine Exazerbation einer chronischen Hepatitis B nach Absetzen des Lamivudins im Rahmen der antiretroviralen Therapie angenommen.

Non-obese hyperlipidemic Asian northern Indian males have adverse anthropometric profile

BACKGROUND AND AIMS

Hyperlipidemia is commonly ascribed to obesity. We studied the association of anthropometric profile and nutrient intake with hyperlipidemia in non-obese Asian Indian males.

METHODS AND RESULTS

In a case-control study, non-diabetic, non-obese males with body mass index (BMI) < 25 Kg/m2 having primary hyperlipidemia (n = 50) were compared with healthy normolipidemic males (BMI < 25 Kg/m2, n = 50). In this study, BMI (p < 0.001), waist circumference (WC) (p < 0.001), waist/hip ratio (p < 0.01), skinfolds (p < 0.001), sum of four skinfolds (p < 0.001), and percentage of body fat (%BF) (p < 0.001) were significantly higher in hyperlipidemic subjects as compared to normolipidemic controls. High %BF (> 25%) was observed in 26% of hyperlipidemic subjects and in 8% normolipidemic controls (p < 0.01). Using analysis of covariance (after adjusting for BMI), WC (p < 0.001), %BF (p < 0.01) and %BF/BMI ratio (p < 0.01) were significantly higher in the hyperlipidemic subjects. Intakes of total calories, total fat, saturated fat, carbohydrates, n-3 and n-6 fatty acids, dietary fiber, vitamin E and n-6/n-3 fatty acids ratio were statistically comparable between the two groups. In hyperlipidemic subjects biceps skinfold correlated negatively to levels of high-density lipoprotein cholesterol (r = -0.28, p < 0.05) and serum triglycerides correlated positively to intakes of carbohydrate (r = 0.31, p < 0.05), and dietary n-3 fatty acids (r = 0.34, p < 0.05).

CONCLUSIONS

Hyperlipidemic Asian Indian males, defined as "non-obese" based on BMI, had adverse profile of anthropometric parameters and excess %BF as compared to normolipidemic males. Therefore, while dealing with hyperlipidemic Asian Indians, physicians should consider anthropometric parameters (WC), %BF, and %BF/BMI ratio in addition to BMI in the clinical assessment.

Cutaneous horn and thermal keratosis in erythema AB igne

A 46-year-old Kashmiri lady developed erythema ab igne on both legs. She subsequently developed multiple keratoses and a cutaneous horn in the involved skin. An uncommon association of these three clinical conditions is being presented.

Rejuvenating facial massage--a bane or boon?

BACKGROUND

Facial massage is an extremely popular form of beauty treatment and is thought to rejuvenate the skin. We decided to study the benefits and untoward effects of this form of facial beauty treatment.

METHODS

One hundred and forty-two women (aged 17-63 years), who had received facial beauty treatment in three well-established beauty parlours in New Delhi, were entered into the study and observed for a period of 12 weeks after the facial beauty treatment. Twenty-seven of the subjects had a repeat facial beauty treatment 4-6 weeks after entry into the study, giving a total of 169 massage episodes observed. Immediate and delayed effects of the beauty treatment were examined.

RESULTS

Facial beauty treatment generally consists of three steps: vigorous massaging of the face with creams, steaming (using a hot towel or a steaming gadget), and application of a face mask containing adsorbents and astringents. In our study, the creams used for massage included "off the shelf" creams manufactured by standard cosmetic companies in 95 (56.3%) subjects, herbal creams in 61 (36.1%), and creams containing exotic ingredients, such as gold salts, in 13 (7.7%). Sixty-one (36.1%) patients developed erythema and puffiness within 15 min to 2 h after the beauty treatment. This lasted for 2-6 h. Forty-one (24.3%) women underwent the procedure of comedone extraction after steaming. In 12 (7.1%) of these women, persistent erythema was noticed at the site of comedone extraction. Eight (4.7%) women developed mild dermatitis on the face, 2-7 days after the facial beauty treatment. Patch testing with constituents used in the facial beauty treatment was positive in four patients (herbal cream, 1; witch hazel, 1; orange face pack, 1; and gold cream, 1). In 47 (33.1%) subjects, an acneiform eruption was observed 3-10 weeks after the facial beauty treatment (mean, 6.1 +/- 3 weeks). Thirteen (27.7%) of these subjects had taken the facial beauty treatment for the first time, whereas 34 (72.3%) developed an acneiform eruption after every facial massage. The predominant lesions were deep-seated nodules, although a few comedones, especially closed ones, were present in some patients. Lesions were always present on the cheeks, an area of focus during the facial massage, and healed with hyperpigmentation. The benefits of facial beauty treatment, as mentioned by the subjects, included a feeling of freshness and rejuvenation in 84 (59.1%), keeping the skin supple in 76 (53.5%), feeling of warmth and tightening of the skin in 71 (50%), and delaying the onset of wrinkles in 21 (14.8%).

CONCLUSIONS

Although there are several subjective benefits with facial beauty treatment, there may be immediate side-effects, such as erythema and edema, as well as delayed problems, such as dermatitis and acneiform eruption, in about one-third of patients.

Cerebral venous thrombosis in ulcerative colitis

Cerebral venous thrombosis is a rare complication of ulcerative colitis. We report a case of 29 year old male who developed superior sagittal, left lateral and sigmoid sinus thrombosis secondary to ulcerative colitis. He was successfully treated with low molecular weight heparin and steroids.

High prevalence of diabetes, obesity and dyslipidaemia in urban slum population in northern India

BACKGROUND AND AIMS

In this study, a prevalence survey of various atherosclerosis risk factors was carried out on hitherto poorly studied rural-urban migrants settled in urban slums in a large metropolitan city in northern India, with the aim of studying anthropometric and metabolic characteristics of this population in socio-economic transition.

DESIGN

A cross-sectional epidemiological descriptive study.

SUBJECTS

A total of 532 subjects (170 males and 362 females) were included in the study (response rate approximately 40%).

METHODS AND RESULTS

In this study, diabetes mellitus was recorded in 11.2% (95% CI 6.8-16.9) of males and 9.9% (95% CI 7.0-13.5) of females, the overall prevalence being 10.3% (95% CI 7.8-13.2). Based on body mass index (BMI), obesity was more prevalent in females (15.6%; 95% CI 10.7-22.3) than in males (13.3%; 95% CI 8.5-19.5). On the other hand, classifying obesity based on percentage body fat (%BF), 10.6% (95% CI 6.4-16.2) of males and 40.2% (95% CI 34.9-45.3) of females were obese. High waist-hip ratio (WHR) was observed in 9.4% (95% CI 5.4-14.8) of males and 51.1% (95% CI 45.8-56.3) of the females. All individual skinfolds and sum of skinfolds were significantly higher in females (P<0.001). In both males and females above 30 y of age, there was a steep increase in the prevalence of high WHR, and in females, %BF was very high (particularly in %BF quartile>30%). Furthermore, total cholesterol and low-density lipoprotein cholesterol were high in both males and females. Stepwise multiple linear regression analysis showed that for both males and females BMI, WHR and %BF were positive predictors of biochemical parameters, except for HDL-c, for which these parameters were negatively associated.

CONCLUSIONS

Appreciable prevalence of obesity, dyslipidaemia, diabetes mellitus, substantial increase in body fat, generalised and regional obesity in middle age, particularly in females, need immediate attention in terms of prevention and health education in such economically deprived populations.

Expression and purification of Dengue virus type 2 envelope protein as a fusion with hepatitis B surface antigen in Pichia pastoris

The methylotrophic yeast, Pichia pastoris, has been used as a host to express the envelope protein (Den2E) of dengue type 2 virus (NGC strain) as a chimera with hepatitis B surface antigen (HBsAg): a protein known to self assemble into virus-like particles (VLPs) and to be efficiently expressed in P. pastoris. The Den2E gene used in this study is a truncated version encoding the first 395 amino acid (aa) residues of the mature Den2E protein; the HBsAg gene encodes the full length 226 aa HBsAg protein. Two in-frame gene fusions were constructed for intracellular expression in P. pastoris. The first one contains the HBsAg gene as the 5' partner and the Den2E gene as the 3'partner (HBsAg-Den2E). In the second one, the relative positions of the two partners of the gene fusion were reversed to create the hybrid Den2E-HBsAg gene. These fusion genes were integrated into the genome of P. pastoris under the control of the methanol-inducible alcohol oxidase (AOX1) promoter. Of the two fusions, the Den2E-HBsAg gene was expressed at higher levels in P. pastoris based on Northern analysis. The hybrid protein ( approximately 68 kDa) expressed by this clone was purified to near homogeneity using a combination of acid precipitation, hydrophobic interaction, and immunoaffinity chromatographic steps. Final purification achieved was approximately 1400-fold with a yield of approximately 26%. The chimeric protein was found to possess the ability to assemble into high molecular weight aggregates (akin to HBsAg particles). The recombinant fusion protein eluted close to the void volume of a Sepharose CL-4B column indicating its macromolecular nature. On a CsCl density gradient the recombinant fusion protein sedimented to a position very similar to that of HBsAg VLPs. The hybrid protein is recognized by the two neutralizing monoclonals against the two components of the chimeric protein.

Adverse profile of dietary nutrients, anthropometry and lipids in urban slum dwellers of northern India

OBJECTIVES

The intra-country rural to urban migrant populations undergo radical socio-economic and lifestyle changes in a developing country. Therefore, it is an interesting sample in which to study nutrition pattern, anthropometry and metabolic profile. The aim of this study was to assess nutrient profile and its association with the anthropometry, percentage body fat (%BF) and blood lipids in the urban slum dwellers in northern India.

DESIGN

A cross sectional epidemiological descriptive study.

SETTINGS

The study was conducted in urban slum colony of Gautam Nagar, situated in a southern area of New Delhi.

SUBJECTS

The data was recorded in 227 subjects (52 males and 175 females).

RESULTS

The diets averaged approximately 59-60% of energy from carbohydrates, 12-13% energy from protein, and 24-27% energy from dietary total fat. Lower intake of monounsaturated fatty acids (MUFA), a low ratio of n-6/n-3 fatty acids, a high ratio of polyunsaturated and saturated fatty acids, a high intake of erucic acid, and a low consumption of fibre and vitamin E intake were significant observations. Although their mean body mass index (BMI) was in a low range (20.5+/-4.2), %BF was high in females (26.7+/-8.6%; P=0.001), and a high prevalence of abdominal obesity was observed in both males (22%) and females (16%). Moreover, there was high prevalence of hypercholesterolemia, hypertriglyceridemia and, in particular, low levels of high-density lipoprotein cholesterol. Those consuming a high-fat diet (>30%) also consumed high MUFA, n-3 fatty acids, saturated fat and dietary cholesterol. Carbohydrate intake as percentage energy was a significant predictor of the levels of triacylglycerol in males, while in females significant predictors for triacylglycerol include intake of carbohydrate as percentage energy, age, %BF and BMI.

CONCLUSION

In this economically deprived population, now constituting approximately 30-50% of the urban population of major cities in India, such adverse dietary, anthropometric and metabolic factors are predictors of early and accelerated atherosclerosis.

SPONSORSHIP

This study was fully supported by a financial grant from the Science and Society Division, Department of Science and Technology, Ministry of Science and Technology, Government of India.

Human papillomavirus absence predicts normal cervical histopathologic findings with abnormal papanicolaou smears: a study of a university-based inner city population

INTRODUCTION

We studied the role of human papillomavirus (HPV) typing in predicting cervical dysplasia in women with abnormal Papanicolaou (Pap) test results.

STUDY DESIGN/METHODS

A university colposcopy clinic-based consecutive sample of 179 women completed a questionnaire and underwent colposcopy, HPV typing (Hybrid Capture System HPV DNA Assay II; Digene Diagnostics, Gaithersburg, MD, USA), and biopsy (if indicated).

RESULTS

No severe dysplasia was observed in women with low-risk HPV or in women with negative HPV test results who had a low-grade abnormality on the Pap test. High-risk (HR) HPV was present in every case of severe dysplasia on biopsy. The cumulative odds risk for cervical dysplasia was 1.11 in HIV(+) women with low-grade squamous intraepithelial lesion on the Pap test who were older than 21 years of age and HPV-HR(+).

CONCLUSIONS

In the population studied, HPV typing is a valuable adjunct to a low-grade abnormality on the Pap test in predicting the absence of cervical dysplasia on biopsy. Larger prospective population-based studies are needed to study the role of HPV as a negative predictor of disease in cervical dysplasia.

Pigmented pleomorphic xanthoastrocytoma: report of a rare case with review of the literature

We describe a rare case of melanotic pleomorphic xanthoastrocytoma in a 32-year-old man who presented with partial complex seizures. Radiologically, the mass was located in the medial temporal lobe and was solid and cystic. Microscopic examination revealed features of a pleomorphic xanthoastrocytoma with some heavily pigmented cells. The pigment was demonstrated to be melanosomal melanin, which was confirmed by special stains, immunohistochemistry, and electron microscopy.