Response to Antiretroviral Therapy among Patients Exposed to Three Classes of Antiretrovirals: Results from the Eurosida Study

There is an increasing proportion of HIV-positive patients exposed to all licensed classes of antiretrovirals, and the response to salvage regimens may be poor. Among over 8500 patients in EuroSIDA, the proportion of treated patients exposed to nucleosides, protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitor (NNRTI) increased from 0% in 1996 to 47% in 2001. Four-hundred-and-thirteen patients, who had failed virologically two highly active antiretroviral therapy (HAART) regimens and experienced all three main drug classes, started a salvage regimen of at least three drugs, in which at least one new PI or NNRTI was included. Median viral load was 4.7 log copies/ml [Interquartile range (IQR) 4.2–5.2], CD4 lymphocyte count 150/mm3 (IQR 60–274/mm3) and follow-up 14 months. Of these patients, 283 (69%) subsequently experienced at least a 1 log decline in viral load and 202 (49%) achieved a viral load <500 copies/ml. Conversely, the CD4 count halved from the baseline value in 88 (21%), and 45 (11%) experienced a new AIDS-defining disease. In multivariable analyses, a 1 log viral load reduction was related to baseline viral load [relative hazard (RH) 1.27 per 1 log higher; P=0.008], a previous viral load of less than 500 copies/ml (RH 1.69; P=0.002), more recent initiation of the regimen (RH 1.36 per year more recent; P=0.02), number of new drugs in the regimen (RH 1.20 per drug; P=0.02), time since start of antiretroviral therapy (RH 0.94 per extra year; P=0.035) and time spent on HAART with viral load >1000 copies/ml (RH 0.96 per extra month; P=0.0001). Analysis of factors associated with CD4 count decline and new AIDS disease also indicated improved outcomes in more recent times and a tendency for a better response in those starting more new drugs, but no relationship with the total number of drugs. Outcomes in people starting salvage regimens appear to depend on the number of new drugs started but not on the total number of drugs being used.

Conventional carbon dioxide application does not reduce cerebral or myocardial damage in open heart surgery

BACKGROUND

Open heart surgery is associated with a significant risk of cerebral and myocardial dysfunction, which is attributed in part to air embolism from incompletely deaired cardiac chambers. To evaluate the impact of carbon dioxide (CO2) insufflation to the thoracic cavity, a prospective randomized study was designed.

METHODS

A total of 62 elective patients were randomly assigned to CO2 insufflation (group I, n = 31) or control (group II, n = 31). According to the Parsonnet risk score, 16 patients in group I (52%) and 10 patients in group II (32%) were categorized as being at either high risk or extremely high risk.

RESULTS

In group II, perioperative mortality was 16.1% (5 patients); in group I, 1 patient died (ns). Creatine kinase MB isoenzyme, as a marker of myocardial damage, was more elevated in group I after surgery (38.0 +/- 4.1 vs 28.0 +/- 2.1, p = 0.02). Neurocognitive test scores did not reveal significant postoperative differences between groups.

CONCLUSIONS

Although mortality was lower with CO2 insufflation, no benefit could be demonstrated for markers of cardiac ischemic damage or neurocognitive outcome in this high-risk population. As CO2 concentrations in the thoracic cavity did not necessarily reach anticipated levels, our method of application is in question.

Treatment of acute hepatitis C with interferon alfa-2b

BACKGROUND

In people who are infected with the hepatitis C virus (HCV) chronic infection often develops and is difficult to eradicate. We sought to determine whether treatment during the acute phase could prevent the development of chronic infection.

METHODS

Between 1998 and 2001, we identified 44 patients throughout Germany who had acute hepatitis C. Patients received 5 million U of interferon alfa-2b subcutaneously daily for 4 weeks and then three times per week for another 20 weeks. Serum HCV RNA levels were measured before and during therapy and 24 weeks after the end of therapy.

RESULTS

The mean age of the 44 patients was 36 years; 25 were women. Nine became infected with HCV through intravenous drug use, 14 through a needle-stick injury, 7 through medical procedures, and 10 through sexual contact; the mode of infection could not be determined in 4. The average time from infection to the first signs or symptoms of hepatitis was 54 days, and the average time from infection until the start of therapy was 89 days. At the end of both therapy and follow-up, 43 patients (98 percent) had undetectable levels of HCV RNA in serum and normal serum alanine aminotransferase levels. Levels of HCV RNA became undetectable after an average of 3.2 weeks of treatment. Therapy was well tolerated in all but one patient, who stopped therapy after 12 weeks because of side effects.

CONCLUSIONS

Treatment of acute hepatitis C with interferon alfa-2b prevents chronic infection.

Cortical fibroblast culture from human biopsies

BACKGROUND

Tubulointerstitial fibrosis is an integral part of progressive renal disease. Human cortical fibroblasts are believed to be key effector cells in fibrogenesis. Thus, a reliable culture of these cells is necessary for studies of their pathophysiology.

METHODS

Cortical fibroblast culture from routine kidney biopsies were analyzed and the cells were characterized. Indirect immunofluorescence staining was done after the first passage for cytokeratin, vimentin, alpha-smooth muscle actin, CD 44, CD 54, CD 68, collagen types I, III, and HLA-DR. We then assessed the utility of the putative fibroblast markers CD 90, prolyl-4-hydroxylase (P4H) and F1b in simultaneous stainings of tubular epithelial cells.

RESULTS

During the study period, 49 biopsy cores were cultured and cortical fibroblasts could be successfully established in 21 cases (42.9%). There was no relation between the success rate of culture and the degree of interstitial fibrosis, but an association was seen with the time of completion of the first passage. There was a negative correlation between the extent of scarring and the percentage of cytokeratin positive cells (r = -0.66, p < 0.001). All primary fibroblasts were negative for factor VIII, HLA-DR, CD 68, and cytokeratin. They expressed alpha-smooth muscle actin and collagen types I and III to variable degrees. There was a robust correlation between the percentage of alpha-smooth muscle actin positive cells and interstitial scarring but no such association with collagen type I or type III positive cells. The three putative fibroblast markers did not prove useful in differentiating between tubular epithelial cells and fibroblasts. However, since only fibroblasts stained positive for CD 90 and negative for cytokeratin, these two markers may suffice to distinguish fibroblasts from other renal cellular elements.

CONCLUSIONS

Cortical renal fibroblasts can be easily cultured from kidney biopsy cores, though the success rate of pure cultures is below 50%. Staining for CD 90 and cytokeratin may suffice for initial characterization of these cells.

Procalcitonin as a parameter of disease severity and risk of mortality in patients with Plasmodium falciparum malaria

The serum levels of procalcitonin (PCT) in Plasmodium falciparum malaria were evaluated for clinical significance in 66 nonimmune and semi-immune patients. Of the 66 patients, 36 had uncomplicated malaria, 24 had severe and complicated malaria, and 6 had fatal malaria (5 from previous studies). Pretreatment PCT concentrations were closely correlated with parasitemia. Concentrations were lowest in semi-immune patients with uncomplicated malaria, compared with those in nonimmune patients (geometric mean concentrations [GMCs], 1.07 and 2.37 ng/mL, respectively), and were highest in severe and complicated cases (GMC, 10.67 ng/mL; P<.001 among all subgroups). Six of 7 patients with PCT concentrations >25 ng/mL died. PCT concentrations decreased on day 2 of treatment in survivors but not in patients with fatal outcome. Thus, repeated PCT measurements may provide useful prognostic information, especially in medical centers that are not experienced in parasite density determination.

Reactivation of hepatitis B virus replication accompanied by acute hepatitis in patients receiving highly active antiretroviral therapy

We describe 2 patients who were initially positive for antibodies to hepatitis B surface antigen and who experienced a strong and sudden increase of hepatitis B virus (HBV) replication during highly active antiretroviral therapy (HAART). We found that reactivation of HBV replication during HAART can occur independently of lamivudine resistance or withdrawal of lamivudine, and in spite of increasing CD4(+) cell counts.

Regional differences in presentation of AIDS in Europe

Data were collected on 6578 patients diagnosed with AIDS at 52 clinical centres in 17 European countries during an 1-year period from 1979 to 1989. The centres were divided into four regions, North, Central, Southeast, and Southwest. Differences in the incidence of most AIDS-defining opportunistic infections and malignancies were found. After adjusting for known possible confounders, statistically significant differences between regions remained. Pneumocystis carinii pneumonia (PCP) was more common in Northern Europe, Kaposi's sarcoma and toxoplasmosis in Central Europe, cytomegalovirus retinitis in South-eastern Europe, and extrapulmonary tuberculosis in South-western Europe. These differences we attribute primarily to different degrees of exposure to the respective underlying pathogens. The prevalence of these and other micro-organisms will determine the clinical course of HIV infections in parts of Eastern Europe and elsewhere where the virus now is spreading.

CD4 alphabeta T lymphocytes express high levels of the T lymphocyte antigen CTLA-4 (CD152) in acute malaria

The role of T lymphocytes in human acute malaria remains under debate. The kinetics of T cell activation in acute malaria were investigated, with emphasis on CTLA-4 (CD152). In patients with malaria, CTLA-4 expression by CD4 alphabeta T lymphocytes was highly increased. After initiation of antiplasmodial treatment, it returned to control values within a few days. gammadelta T cells, which also are implicated in the pathogenesis of human malaria, did not express CTLA-4. The level of CTLA-4 expression at the time of hospital admission was correlated positively with other markers of disease severity-the peak of the parasitemia and the peak of serum neopterin levels. These results show that CTLA-4 is a sensitive and dynamic marker for T lymphocyte activation. Its strong increase in acute malaria argues for the involvement of T cells in the human immune response to plasmodia.

Increased levels of soluble Fas ligand in serum in Plasmodium falciparum malaria

Levels of soluble Fas ligand (sFasL) in serum were elevated in patients with Plasmodium falciparum malaria and showed a significant decline during disease course. sFasL levels that were elevated before antimalarial treatment began correlated significantly with depressed total lymphocyte and T-cell counts. These data suggest that Fas-induced apoptosis might play a role in malaria-associated lymphopenia.

Comparative evaluation of two branched-DNA human immunodeficiency virus type 1 RNA quantification assays with lower detection limits of 50 and 500 copies per milliliter

We have comparatively evaluated Quantiplex version 3.0 and version 2. 0 on 133 plasma samples and a repetitive dilution series. Version 3. 0 yielded higher human immunodeficiency virus RNA values, and the ratio of version 3.0 results to version 2.0 results decreased from 3. 47 below 1,000 copies/ml to 1.97 above 50,000 copies/ml [linear regression, log (version 3.0) = 0.915 + 0.871 x log (version 2.0); r(2) = 0.952].

High levels of inducible nitric oxide synthase mRNA are associated with increased monocyte counts in blood and have a beneficial role in Plasmodium falciparum malaria

To date, there have been conflicting reports concerning the clinical significance of nitric oxide (NO) in Plasmodium falciparum malaria. Some authors have proposed that NO contributes to the development of severe and complicated malaria, while others have argued that NO has a protective role. To investigate these apparently contradictory reports, reverse transcription-coupled PCR was used to study inducible NO synthase (iNOS) in whole-blood RNA samples from patients with severe and complicated malaria or uncomplicated malaria and from healthy donors. This work produced three principal findings. First, samples of patients with severe and complicated malaria were variably positive, with weak to moderate intensity. Markedly higher iNOS RNA levels were observed in samples of patients with uncomplicated malaria than in patients with severe and complicated malaria. Samples of healthy donors were uniformly negative. Second, since we initially demonstrated iNOS expression in whole-blood RNA samples, we extended our investigations to individual blood cells such as monocytes, lymphocytes, neutrophils, and platelets to identify the cellular source of iNOS. We found that iNOS was expressed predominantly in monocytes. Third, retrospective statistical analysis of monocyte counts clearly demonstrated that patients with uncomplicated malaria had higher monocyte counts at the time of presentation than patients with severe and complicated malaria. Taken together, our findings give room to the interpretation that NO may have a beneficial rather than a deleterious role in falciparum malaria.

Anaemia is an independent predictive marker for clinical prognosis in HIV-infected patients from across Europe. EuroSIDA study group

OBJECTIVES

To describe changes in haemoglobin over time and to determine the joint prognostic value of the current haemoglobin, CD4 lymphocyte count and viral load among patients from across Europe.

PATIENTS

The analysis included 6725 patients from EuroSIDA, an observational, prospective cohort of patients with HIV from across Europe.

METHODS

Normal haemoglobin was defined as haemoglobin greater than 14 g/dl for men and 12 g/dl for women; mild anaemia was 8-14 g/dl for men and 8-12 g/dl for women; severe anaemia was defined as less than 8 g/dl for both males and females. Linear regression techniques were used to estimate the annual change in haemoglobin; standard survival techniques were used to describe disease progression and risk of death.

RESULTS

At recruitment to the study, 40.4% had normal levels of haemoglobin, 58.2% had mild anaemia and 1.4% had severe anaemia. At 12 months after recruitment, the proportion of patients estimated to have died was 3.1% [95% confidence interval (CI) 2.3-3.9] for patients without anaemia, 15.9% for patients with mild anaemia (95% CI 14.5-17.2) and 40.8% for patients with severe anaemia (95% CI 27.9-53.6; P < 0.0001). In a multivariate, time-updated Cox proportional hazards model, adjusted for demographic factors, AIDS status and each antiretroviral treatment as time-dependent covariates, a 1 g/dl decrease in the latest haemoglobin level increased the hazard of death by 57% [relative hazard (RH) 1.57; 95% CI 1.41-1.75; P < 0.0001], a 50% drop in the most recent CD4 lymphocyte count increased the hazard by 51% (RH 1.51; 95% CI 1.35-1.70; P < 0.0001) and a log increase in the latest viral load increased the hazard by 37% (RH 1.37; 95% CI 1.15-1.63; P = 0.0005).

CONCLUSIONS

Severe anaemia occurred infrequently among these patients but was associated with a much faster rate of disease progression. Among patients with similar CD4 lymphocyte counts and viral load, the latest value of haemoglobin was a strong independent prognostic marker for death.

Enhanced expression of CTLA-4 (CD152) on CD4+ T cells in HIV infection

CTLA-4 (CD152) is a surface molecule of activated T cells with sequence homology to CD28. Both molecules bind to the same ligands, B7.1 (CD80) and B7.2 (CD86) but have antagonistic functions. While CD28 is an important costimulator, CTLA-4 has an essential inhibitory function in maintaining the homeostasis of the immune system. Down-regulation of CD28 predominantly on CD8+ T cells has been described in HIV infection, but analysis of CTLA-4 is complicated by its low expression levels. Here we have used potent signal enhancement to study CTLA-4 on peripheral blood mononuclear cells (PBMC) during HIV infection. CTLA-4 was expressed only on T cells. Expression levels were significantly increased selectively on CD4+ T cells during all stages of HIV infection, while CTLA-4 expression on CD8+ T cells was always low. In contrast, after stimulation with the mitogen phytohaemagglutinin (PHA), CTLA-4 levels were strongly increased on T cells from controls but in T cells from HIV patients this response was severely impaired. Our data suggest that in HIV infection CD4+ and CD8+ T cells may be less responsive to B7 costimuli due to two different mechanisms: increase in CTLA-4 expression by CD4+ cells and down-regulation of CD28 by CD8+ cells.

Low levels of fibrin-stabilizing factor (factor XIII) in human Plasmodium falciparum malaria: correlation with clinical severity

Plasmodium falciparum malaria is associated with procoagulant activity but not with thromboembolism. We measured coagulation factor XIII, i.e., fibrin-stabilizing factor, in 45 patients with falciparum malaria over time. Of these, 22 had organ complications. The factor XIII antigen (subunits A and B) and plasma activity levels were abnormally low in those with falciparum malaria. They increased during antiparasitic therapy. In 14 of 22 patients with complications, but in no patient with mild disease (P < 0.001), subunit A and activity was < 50%. The factor X.III levels were inversely correlated with clinical severity, parasitemia, and human neutrophil elastase (HNE), but not with thrombin-antithrombin III levels. Thus, low factor XIII levels may reflect proteolysis by HNE, rather than procoagulant activity. One could speculate that factor XIII degradation in severe malaria prevents thromboembolism. On the other hand, factor XIII deficiency might reduce protection of the vascular endothelium against HNE and reactive oxygen species, which would promote organ damage.

Limitations of the evaluation of adnexal masses by its macroscopic aspects, cytology and biopsy

To investigate the relevance of intraoperative macroscopic evaluation of adnexal masses a prospective study was conducted from June 1st, 1993 to May 31st, 1994, which included 57 premenopausal and 60 postmenopausal women, who underwent laparotomy because of a cystic adnexal mass. The surgeons were asked to classify the tumor intraoperatively as benign or malignant and to assign to histologic groups. In addition cytology of the cyst fluid and a biopsy from the cystic wall were evaluated. Comparison of these items with the results of permanent section diagnosis revealed the tendency of the surgeons to underestimate adnexal masses depending on patients' age and the complexity of the tumor, despite of the knowledge of preoperative ultrasonographic findings. Sufficient cytolologic examination was possible in only one third of aspirates and only 21% of the examined postmenopausal malignant neoplasms have correctly been diagnosed by cytology. Evaluation of the biopsy specimens demonstrates a marked percentage of false negatives with respect to benign tumors (30% of non-functional benign neoplasms in the premenopause were assessed as functional cysts) as well as malignant neoplasms (only 72% were diagnosed correctly in the postmenopause group). In conclusion intraoperative subjective assessment, cytology and representative biopsies do not necessarily concur with the definitive histological diagnosis.

[Clinical results of primary intramedullary osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft fractures]

From 04/91 to 06/96 sixty-nine open fractures of the tibia were primarily treated on the day of the accident with unreamed nailing (UTN, Synthese). The distributions of fracture type according to the AO classification and of soft tissue injury according to Gustilo were as follows: fracture type: A: 28%, B: 52%, C: 20%; soft tissue injury: I: 30%, II: 28%, IIIA: 12%, IIIB: 12%, IIIC: 6%. Of the 65 fractures assessed 46 (71%) healed within 18 weeks without secondary intervention. There was delayed healing in three fractures requiring secondary conversion to reamed nailing. Eight fractures (12%) developed pseudarthrosis of which five (8%) healed uneventfully. Deep infections was manifest in four fractures (6%). Three of these infections developed after secondary intervention to treat pseudarthrosis. Seven of the eight pseudarthroses and three of the four infections healed eventually. Revision procedures were necessary in 11 patients (17%) to deal with disturbed fracture healing or infection (10 reamed nailing procedures, three cancellous bone grafts, and one of each of the following: sequestrectomy, fibular osteotomy, plate fixation, external fixator, monorail procedure). The results show that the same good infection rates were achieved for the UTN as for the external fixator. The advantages of the UTN are, however, a lesser need for secondary intervention and greater patient comfort. Therefore, we find the UTN to be a good alternative to the external fixator in the treatment of open fractures with severe soft tissue damage.

Sonomorphology of endometriotic cysts

OBJECTIVE

The aim of the study was to evaluate prospectively the sonomorphological feature of histologically verified endometriotic cysts.

METHODS

Transvaginal sonography was performed in 122 patients. Age distribution of the patients, and size and sonomorphology of the lesions were analyzed.

RESULTS

Eighty-one percent of the endometriotic cysts occurred in patients between 31 and 50 years old with a peak of 29% between 31 and 35 years. Most of the cysts (81%) ranged between 30 and 59 mm in diameter. Forty-three percent of the endometriotic cysts were observed as monolocular cysts with internal echoes. More than half of the findings were observed to be multilocular, partially without any internal echos, partially even with solid parts or purely solid.

CONCLUSION

The so-called 'typically' monolocular smooth-walled endometriotic cyst with internal echoes was only found in 43% of the cases. However, data from the literature show that one cannot assume even this special entity to represent endometriomas. Regarding all monolocular cysts with homogeneous internal echoes, one has to be aware of a great amount of functional cysts and a non-calculable residual risk of malignancy.

Neuropsychological changes after cardiopulmonary bypass for coronary artery bypass grafting

BACKGROUND

An alarming incidence (1% to 83%) of neuropsychological dysfunction has been reported after operations using cardiopulmonary bypass (CPB). The present clinical study re-evaluates these complications with current CPB technology in a strictly selected low-risk group of coronary artery bypass (CABG) patients.

METHODS

76 CABG patients, without history of stroke or internal carotid artery stenosis, were examined before, 5 days after, and 2 months after surgery. A neuropsychological test battery was employed according to the "Statement of Consensus on Assessment of Neurobehavioral Outcomes after Cardiac Surgery". Tests include the Block Design Test (problem-solving strategies, recognition and analysis of forms), the Trail Making Test (cognitive achievement at speed), and the Digit Span Test (short-term memory and memory of figures).

RESULTS

Both postoperative test scores were not significantly decreased as compared to preoperative values. In contrast, neuron specific enolase (NSE) and S100 b protein, biochemical markers of cerebral injury, increased markedly during and immediately after surgery (NSE preop.: 7.07 +/- 2.40 ng/ml, 1 h postop.: 13.64 +/- 4.50 ng/ml, p < 0.001; S100 b preop.: 0.04 +/- 0.07 ng/ml, after crossclamp: 0.90 +/- 0.69 ng/ml, p < 0.001). One patient displayed postoperative transitional syndrome, another patient suffered from transitory paresis and hypesthesia of the left arm, which disappeared during hospital stay.

CONCLUSIONS

Biochemical markers demonstrate significant postoperative cerebral injury during and immediately after CPB. However, CPB for CABG does not lead to marked impairment of neuropsychological scores, and clinically relevant neurological findings were observed in one patient only.

Patterns of mycobacterium avium culture and PCR positivity in immunodeficient HIV-infected patients: progression from localized to systematic disease, German Aids Study Group (GASG/IDKF)

Our aim was to establish the frequency and the longitudinal pattern of MAC culture positivity in late stage HIV-infected patients. Two other aims were to analyse risk factors for progression from localized to systemic disease and the value of PCR diagnosis using blood specimens. A total of 107 patients were recruited to be followed for 32 weeks. Prior MAC treatment and CD4 > 100/microliters were exclusion criteria. A total of 56 patients showed M. avium in at least 1 culture. 10/37 patients with MAC detected by culture first in 'non-sterile' specimens (stool, sputum) and urine progressed to systemic disease as determined by positive blood culture. Risk factors associated with this progression were a high symptom score at baseline, lymphadenopathy, anaemia, and low platelets. PCR was less sensitive than culture in detection of M. avium in blood specimens: Only 7/29 patients with positive blood cultures had a positive PCR at the same time. We conclude that symptomatic patients with advanced HIV-infection have a high frequency of MAC detection. Progression from localized to systemic culture positivity is associated with risk factors. Early 'pre-emptive' therapy is discussed.

Prognostic value of angiogenesis in mammary tumors

Vessel density counting has been performed in a variety of tumors and used as predictive parameter for the tumor's malignant behavior (metastasis, five year survival). A number of studies have reported conflicting results on the predictive value of vessel density counts. We have quantitated the number of microvessels in routine pathology specimens of paraffin embedded mammary tumors and related these findings to the histopathological diagnosis. Average vessel density counts of vascular hot spots of malignant and benign mammary tumors were similar (34 +/- 15 vs. 31 +/- 10), though significantly higher as in the adjacent normal mammary tissue (12 +/- 5). Analysis of individual tumors, however, showed that significantly more malignant than benign tumors had vessel density counts beyond a defined cut-off value (50 microvessels/HPF). The results suggest that high counts may indeed serve as an independent prognostic parameter. In contrast, low counts may also be observed in malignant tumors and may, thus, not be used as negative prognostic factor.

Fetal plasma levels of circulating endothelial cell adhesion molecules in normal and preeclamptic pregnancies

OBJECTIVE

Circulating levels of endothelial cell adhesion molecules are elevated in women with preeclampsia. The aim of the present study was to determine levels of these molecules in the fetal circulation of normal pregnancies and pregnancies complicated by preeclampsia.

STUDY DESIGN

Fetal plasma samples from the umbilical vein and peripheral maternal plasma and serum sample were collected at delivery from women with preeclampsia and women with normal pregnancy. Women with non-proteinuric pregnancy-induced hypertension (PIH) were excluded from the study. A sandwich ELISA technique was employed to quantitate concentrations of soluble ICAM-1 (CD54), VCAM-1 (CD106), and E-selectin (CD62E).

RESULTS

The normal values of soluble endothelial cell adhesion molecules in the fetal circulation were determined as 162+/-45 ng/ml for ICAM-1, 1612+/-582 ng/ml for VCAM-1, and 154+/-58 ng/ml for E-selectin. They were found to markedly differ from the corresponding normal values in the maternal circulation (sICAM-1: 247+/-65 ng/ml; sVCAM-1: 715+/-170 ng/ml; sE-selectin: 34+/-14 ng/ml). The concentrations of sICAM-1, sVCAM-1, and sE-selectin were significantly elevated in women with preeclampsia compared to healthy control pregnant women. In contrast, there was no difference in the circulating fetal concentrations of these molecules between normal pregnancies and pregnancies complicated by preeclampsia.

CONCLUSIONS

Normal values of sICAM-1, sVCAM-1, and sE-selectin in fetal circulation are markedly different from the values obtained for healthy adults. Plasma concentrations of these molecules are elevated in women with preeclampsia but not in the fetal circulation of preeclamptic pregnancies suggesting that based on the analysis of soluble adhesion molecules the fetal circulation may not be affected by the factor(s) that lead to disturbed endothelial cell function in women with preeclampsia.

Regional differences in use of antiretroviral agents and primary prophylaxis in 3122 European HIV-infected patients. EuroSIDA Study Group

Little is known about how widely HIV-related drugs are used outside controlled clinical trials. We therefore assessed factors associated with use of antiretroviral (ARV) therapy and primary prophylactic regimens to prevent HIV-associated opportunistic infections. Baseline data from a prospective study from May to August 1994, on 3122 consecutive HIV infected patients with a CD4 count <500 cells/microl, followed in 37 centers from 16 European countries, were analyzed. Two thousand and twenty patients (65%) were receiving at least 1 ARV drug at the time of the study. ARV therapy was more frequently used among patients from southern and central Europe as compared with patients from northern Europe, especially among patients with CD4 counts >200 cells/microl (73%, 57%, and 42%, respectively, p < 0.0001). Of patients on ARV therapy, 34% received open-label combination therapy. This proportion was higher in central Europe compared with other regions (27%, 50%, and 31% for southern, central, and northern Europe, respectively, p < 0.0001). Primary prophylaxis against Pneumocystis carinii pneumonia (PCP) was used by 85% of patients with a CD4 count <200 cells/microl, without marked regional differences. In patients without esophageal candidiasis or other invasive fungal infections, antifungal drugs were far less frequently used in patients from southern and central Europe compared with patients from northern Europe (10%, 10%, and 25%, respectively, p < 0.0001). Only 5% of patients with a CD4 count <100 cells/microl received rifabutine as primary prophylaxis against nontuberculous mycobacterioses. ARV and antifungal therapies are used differently in different parts of Europe, whereas primary PCP prophylaxis is uniformly administered to most at-risk patients. U.S. recommendations on the use of antimycobacterial prophylaxis have not been implemented in Europe.