Discontinuation of anticytomegalovirus therapy in patients with HIV infection and cytomegalovirus retinitis

CONTEXT

Persons with cytomegalovirus (CMV) retinitis and acquired immunodeficiency syndrome (AIDS) have required lifelong anti-CMV therapy to prevent the progression of retinal disease and subsequent loss of vision.

OBJECTIVE

To determine whether patients who were taking highly active antiretroviral therapy (HAART) and who had stable CMV retinitis could safely discontinue anti-CMV therapy without reactivation of their retinitis or increase in human immunodeficiency virus (HIV) viral load.

DESIGN

Prospective nonrandomized interventional trial performed from July 1997 to August 1999.

SETTING

Clinical Center of the National Institutes of Health, Bethesda, Md.

PATIENTS

Fourteen patients with stable CMV retinitis and HIV infection and CD4+ cell counts higher than 0.1 5 x 10(9)/L and being treated with systemic anti-CMV medications and HAART.

INTERVENTIONS

Discontinuation of specific anti-CMV therapy.

MAIN OUTCOME MEASURES

Reactivation of CMV retinitis, development of extraocular CMV infection, detection of CMV in blood and urine, HIV burden, immunologic function, quality of life, morbidity, and mortality.

RESULTS

Twelve (89.7%) of 14 patients had evidence of immune recovery uveitis before anti-CMV drugs were discontinued. No patient had reactivation of CMV retinitis or development of extraocular CMV disease during mean follow-up of 16.4 months (range, 8.3-22.0 months) without anti-CMV therapy. Human immunodeficiency viral load remained stable following cessation of anti-CMV medications. Blood and urine assays for CMV were briefly positive in 9 patients but did not predict reactivation of CMV disease. Worsening immune recovery uveitis was associated with a substantial (>3 lines) vision loss in 3 patients.

CONCLUSIONS

Maintenance anti-CMV medications were safely stopped in those patients who had stable CMV retinitis and elevated CD4+ cell counts and who were taking HAART. The study demonstrates that immune recovery following potent antiretroviral therapy is effective in controlling a major opportunistic infection, even in patients with a history of severe immunosuppression.

A position-sensitive Stroop effect: further evidence for a left-to-right component in print-to-speech conversion

In the classical Stroop effect, response times for naming the color in which a word is printed are affected by the presence of semantic, phonological, or orthographic relationships between the stimulus word and the response word. We show that color naming responses are faster when the printed word shares a phoneme with the color name to be produced than when it does not, in conditions where there is no semantic relationship between the printed word and the color name. This result is compatible with a variety of computational models of reading. However, we also found that these effects are much larger when it is the first phoneme that the stimulus and response share than when it is the last. Our data are incompatible with computational models of reading in which the computation of phonology from print is purely parallel. The dual route cascaded model computational model of reading, which has a lexical route that operates in parallel and a nonlexical route that operates serially letter by letter, successfully simulates this position-sensitive Stroop effect. The model also successfully simulates the "onset effect" in masked priming (Forster & Davis, 1991) and the interaction between the regularity effect and the position in a word of a grapheme-phoneme irregularity (Rastle & Coltheart, 1999b)--effects which, we argue, arise for the same reason as the position-sensitive Stroop effect we report.

Factors influencing food choices of adolescents: findings from focus-group discussions with adolescents

OBJECTIVE

To assess adolescents' perceptions about factors influencing their food choices and eating behaviors.

DESIGN

Data were collected in focus-group discussions.

SUBJECTS/SETTING

The study population included 141 adolescents in 7th and 10th grade from 2 urban schools in St Paul, Minn, who participated in 21 focus groups.

ANALYSIS

Data were analyzed using qualitative research methodology, specifically, the constant comparative method.

RESULTS

Factors perceived as influencing food choices included hunger and food cravings, appeal of food, time considerations of adolescents and parents, convenience of food, food availability, parental influence on eating behaviors (including the culture or religion of the family), benefits of foods (including health), situation-specific factors, mood, body image, habit, cost, media, and vegetarian beliefs. Major barriers to eating more fruits, vegetables, and dairy products and eating fewer high-fat foods included a lack of sense of urgency about personal health in relation to other concerns, and taste preferences for other foods. Suggestions for helping adolescents eat a more healthful diet include making healthful food taste and look better, limiting the availability of unhealthful options, making healthful food more available and convenient, teaching children good eating habits at an early age, and changing social norms to make it "cool" to eat healthfully.

APPLICATIONS/CONCLUSIONS

The findings suggest that if programs to improve adolescent nutrition are to be effective, they need to address a broad range of factors, in particular environmental factors (e.g., the increased availability and promotion of appealing, convenient foods within homes schools, and restaurants).

Testing a computational account of category-specific deficits

Patients displaying mild symptoms of Alzheimer's disease sometimes have more difficulty naming items from an artifact than from a natural kind category; others displaying more severe symptoms almost always have more difficulty naming items from a natural kind than from an artifact category. This paper examined a computational model of this double dissociation (Devlin, Gonnerman, Andersen, & Seidenberg, 1998). Four basic tests of the model were proposed: The model should be able to generalize to new exemplars, the model should be expandable such that training sets of a realistic size can be used, the model's performance should not be unduly affected by small changes in architecture, and the learning algorithm should produce results that are not inconsistent with any major underlying factor of semantic organization. The model was found to be deficient in all four areas. Results reported from the model may therefore have been idiosyncratic to the model and not reflect general properties of a real semantic system.

Integration of plastic surgery in the course of breast-conserving surgery for cancer to improve cosmetic results and radicality of tumor excision

Integration of plastic surgery is currently widely practiced in cases of mastectomy. Immediate breast reconstruction with an implant or autologous tissue procedures is frequently proposed to the patient before the mastectomy. However, breast conserving surgery (BCS) is recognized as the treatment of choice in most cancers: breast conservation is proposed in more than 70% of the patients with primary cancer treated at the European Institute of Oncology in Milan. This high percentage of preservation has been made possible by the integration of plastic surgery at the time of primary surgery. The size of the tumorectomy remains a matter of discussion. Based on the Milan II trial and Holland's pathological studies, Veronesi recommended so-called "local radical surgery." For a tumor 1 cm in size, a free margin of 2 cm produces a final specimen at least 5-6 cm in diameter. In small or medium-sized breasts, such a resection results in a wide glandular defect and poor esthetic results if direct closure is carried out. Plastic surgery derived from reduction mammaplasty procedures allows much better final cosmetic results, which is the goal of conservative treatment. In 25% of our patients treated with BCS, the plastic surgeon is called upon by the general surgeon to close the glandular defect. However, such glandular remodeling changes the size and position of the breast. Therefore, in 15% of these cases a symmetry procedure is performed on the opposite breast. The reduction procedure in the opposite breast should be taken as a good opportunity to check the glandular tissue. Special attention should therefore be given to the contralateral mammogram in order to focus the glandular resection on the most dubious areas. Occult carcinomas, half of them infiltrating, were found in 4% of a series of 350 symmetry procedures performed during breast reconstruction at the Gustave Roussy Cancer Institute. In conclusion, close collaboration between oncologists and plastic surgeons is required not only to obtain the best cosmetic results but also to allow improved radicality of the tumor resection and a histological check-up of the contralateral breast.

Distinct ICAM-1 forms and expression pathways in synovial microvascular endothelial cells

Human synovial endothelial cell (HSE) intracellular adhesion molecule-1 (ICAM-1) is upregulated maximally by synergy of tumor necrosis factor alpha (TNF alpha) and interferon gamma (IFN gamma). Such synergy is not as pronounced in human umbilical vein endothelium (HUVE). ICAM surface staining and ELISA detection reflected similar levels on HUVE and HSE cells, yet mRNA levels were much higher in HSE cells in response to TNF alpha/IFN gamma. To correlate protein and mRNA levels of ICAM-1, both cell types were permeabilized and stained with a monoclonal antibody against ICAM-1. HSE cells displayed a distinct vesicular cytoplasmic staining for ICAM while HUVE cells were devoid of such stained vesicles upon staining with the antibody. ICAM-1 immunostaining of HSE cytoplasmic vesicles appeared enhanced in cells treated with TNF alpha/IFN gamma and monensin, an endosomal processing inhibitor. Monensin inhibited HSE cell surface expression of ICAM-1 routinely up to 70%, while HUVE cell expression was unaffected. In addition, monensin also inhibited soluble ICAM-1 release from HSE cells while not effecting HUVE cells. Immunoprecipitation of ICAM-1 followed by gel electrophoresis indicated that HUVE and HSE cell ICAMs are expressed in cell-specific forms. These results define distinct forms and distinct secretory pathways for ICAM-1 in HSE cells and HUVE cells that indicate functional differences between these human endothelia.

Adolescent alcohol use and the community health agenda: a study of leaders' perceptions in 28 small towns

The study assessed leaders' perceptions of adolescent alcohol use as a public health issue in 28 small communities in northern Minnesota, as part of formative evaluation for a community-based intervention to reduce adolescent alcohol access and consumption. One hundred and eighteen leaders from five key community sectors were interviewed about their perceptions of social, health and alcohol-related problems in their communities. Analyses indicated that school representatives and police chiefs perceived adolescent alcohol use and related problems to be serious; newspaper editors mentioned other social problems more often; and mayors and business representatives did not perceive adolescent alcohol problems to be as serious. In relation to efforts to affect local policy, the study suggested government and business sectors in these communities may need to be educated about the problem to build its importance on the community agenda of health issues. Thus community leaders in some sectors may comprise a key target audience for intervention.

Informed consent in research

The relationship between physician and patient, as generally delineated by the Hippocratic Oath and the American Medical Association's 1994 Principles of Medical Ethics, is one between a fiduciary and a principal. In such a relationship, the duties of loyalty and trust run from the fiduciary to the principal. The fiduciary (physician) is the person to whom the relevant interests of the principal (patient) are entrusted. It is the medical best interests of the patient, not the physician, that are in trust. The relationship, while usually gratifying and financially rewarding, is essentially one of professional altruism. Nevertheless, the satisfaction of this fiduciary obligation requires the performance of general duties at levels dictated by the nature and scope of medical intervention.

Three major issues in infection control

In considering the three major issues in infection control the author decided upon education and empowerment, community practices, and research availability and application as they span a range of infection control practices and healthcare settings. Education and empowerment of staff is needed to ensure safe practice. This requires collaboration between education providers and infection control personnel and should be available to all disciplines of staff. Infection control needs to be seamless across the primary and secondary care interface and must include infection prevention advice to the population in general. Evidence relating to infection control is either lacking or not achievable. When it is available, it is not always implemented because of lack of resources.

New techniques for biopsy and culture of human olfactory epithelial neurons

OBJECTIVE

To improve the success of culturing olfactory neurons from human nasal mucosa by investigating the intranasal distribution of the olfactory epithelium and devising new techniques for growing human olfactory epithelium in vitro.

DESIGN

Ninety-seven biopsy specimens were obtained from 33 individuals, aged 21 to 74 years, collected from 6 regions of the nasal cavity. Each biopsy specimen was bisected, and 1 piece was processed for immunohistochemistry or electron microscopy while the other piece was dissected further for explant culture. Four culture techniques were performed, including whole explants and explanted biopsy slices. Five days after plating, neuronal differentiation was induced by means of a medium that contained basic fibroblast growth factor. After another 5 days, cultures were processed for immunocytochemical analysis.

RESULTS

The probability of finding olfactory epithelium in a biopsy specimen ranged from 30% to 76%, depending on its location. The dorsoposterior regions of the nasal septum and the superior turbinate provided the highest probability, but, surprisingly, olfactory epithelium was also found anteriorly and ventrally on both septum and turbinates. A new method of culturing the olfactory epithelium was devised. This slice culture technique improved the success rate for generating olfactory neurons from 10% to 90%.

CONCLUSIONS

This study explains and overcomes most of the variability in the success in observing neurogenesis in cultures of adult human olfactory epithelium. The techniques presented here make the human olfactory epithelium a useful model for clinical research into certain olfactory dysfunctions and a model for the causes of neurodevelopmental and neurodegenerative diseases.

No more problems in Coltheart's neighborhood: resolving neighborhood conflicts in the lexical decision task

In the area of visual word recognition, there is considerable disagreement as to whether neighborhood effects for words in the lexical decision task are facilitatory or inhibitory: While they seem to be mostly facilitatory in English, they tend to be absent or inhibitory in French or Spanish. The present study investigated the possibility that the facilitatory neighborhood effect obtained in English is due to the fact that most neighbors in English are body neighbors (i.e. they share the same orthographic rime). Our results showed that when words were matched for orthographic neighborhood (N), the effects of body neighbors (BN) were facilitatory (i.e. shorter reaction times for words with many body neighbors than for words with few body neighbors). In contrast, when words are matched for BN, the effects of N are unreliable with a tendency towards inhibition. In conclusion, it appears that research conducted in English has always found neighborhood effects to be facilitatory because of the dominant role of body neighbors in English. In contrast, neighborhood effects in French and Spanish may have been more ambiguous because these languages either do not confound N and BN, or they do not require a greater sensitivity to the body/rime unit.

Outbreak of Shigella sonnei in a clinical microbiology laboratory

Laboratory technologists (22%) developed infections with Shigella sonnei. The isolates had the same antibiogram and pulse-field gel electrophoresis pattern as an unknown isolate handled by a laboratory student. Covering faucet handles with paper towels during hand washing in the laboratory was protective. No further cases occurred after the laboratory was cleaned with a phenolic agent and a handle-free faucet was installed.

[Macroenzymes: an interesting laboratory finding, without clinical relevance]

Macroenzymes are complexes of serum enzymes with proteins which have a higher molecular weight and longer plasma half-life than the normal enzyme. The presence of macroenzymes is suggested by finding increased serum enzyme activity, not associated with symptoms. Thus, macroenzymes can cause diagnostic errors and the performance of unnecessary tests or invasive procedures. We describe 2 patients with highly elevated serum levels of lactate dehydrogenase (LDH) and creatine kinase (CK) due to formation of complexes with immunoglobulin G. 1 patient had LDH of 4500 u/L but was otherwise normal and in the second CK was elevated with no evidence of ischemic heart disease. Awareness of the phenomenon of macroenzymes may save the patient long and sometimes invasive investigation.

Increased toxicity of high-dose furosemide versus low-dose dopamine in the treatment of refractory congestive heart failure

OBJECTIVE

To evaluate the safety and efficacy of low-dose dopamine, high-dose furosemide, and their combination in the treatment of refractory congestive heart failure.

METHODS

Twenty consecutive patients with refractory congestive heart failure were randomized to receive intravenous low-dose (4 micrograms/kg/min) dopamine combined with low-dose (80 mg/day) oral furosemide (group A; n = 7), intravenous low-dose dopamine with medium-dose furosemide (5 mg/kg/day through continuous intravenous administration; group B; n = 7), or high-dose furosemide (10 mg/kg/day through continuous intravenous administration; group C; n = 6).

RESULTS

The three groups showed similar improvement in signs and symptoms of congestive heart failure, urinary output (2506 +/- 671 ml/24 hr, mean +/- SD) and weight loss (3.3 +/- 2.3 kg) after 72 hours of therapy. Mean arterial blood pressure (MAP) decreased by 14% +/- 8% and 15% +/- 6% in groups B and C, respectively, but increased by 4% +/- 15% in group A (p = 0.017). Renal function deteriorated significantly in groups B and C: creatinine clearance decreased by 41% +/- 23% and 42% +/- 23%, respectively, but increased by 14% +/- 35% in group A (p = 0.0074). MAP decrease was positively correlated with the decrease in creatinine clearance (r = 0.7; p = 0.0007). Patients in group B and C had more hypokalemia than group A. Two patients in group C sustained acute oliguric renal failure and one patient in group B died suddenly while sustaining severe hypokalemia.

CONCLUSION

Combined low-dose intravenous dopamine and oral furosemide have similar efficacy but induce less renal impairment and hypokalemia than higher doses of intravenous furosemide taken either alone or with low-dose dopamine. The renal impairment induced by intravenous furosemide is probably related to its hypotensive effect in patients with refractory congestive heart failure.

Admissibility and per se exclusion of hypnotically elicited recall in American courts of law

State v. Mack (1980) ruled that hypnotically elicited testimony is per se excluded from Minnesota law courts; this court also ruled that police could employ hypnosis in an attempt to construct an independently corroborated case. In recent years, there have been moves to rescind this exclusion; this raises a question of the probative value of such additional information when it is uncorroborated. This situation is compared with that of the polygraph as an index of deception: Like hypnosis, it is excluded per se in most American jurisdictions. Some legal decisions in Wisconsin are used to illustrate one alternative to the per se exclusion approach. Admissibility of scientific evidence in American courts of law has been based on a criterion of "general acceptability within the relevant scientific community," as first elucidated in Frye v. United States (1923). Recently, the U.S. Supreme Court overturned the Frye decision in Daubert v. Merrell Dow Pharmaceuticals, Inc. (1993), by making general acceptability but one of several admissibility criteria. Three Daubert-based decisions, one involving hypnosis and all concerned with "recovered repressed memories," indicate some problems in law posed by Daubert.

Control of varicella-zoster infection on renal and other specialist units

The introduction of chickenpox onto our renal unit recently raised several issues surrounding the management of patient and staff contracts. This paper describes the action taken and makes various recommendations for future management of similar cases. Guidelines are proposed for the management of patients and staff as well as the role of the infection control team in handling a chickenpox problem. Future developments, including the use of VZ vaccine for patient and staff, are also discussed.