Successful duloxetine treatment of a binge eating disorder: a case report

We report the successful treatment of a case of refractory binge eating disorder (BED) with duloxetine, a combined serotonin and norepinephrine reuptake inhibitor, resulting in complete remission of the patient's bingeing behaviours. This case is discussed in the context of the existing literature on the psychopharmacology of BED. Results demonstrate that inhibition of 5-HT and noradrenaline reuptake by duloxetine markedly reduces food intake, suggesting that this may be a novel approach for the treatment of obesity.

Noradrenergic function in pathological gambling: blunted growth hormone response to clonidine

The noradrenergic system has been linked to impulsive behaviour in animals and humans, yet little data on noradrenergic system exist in specific impulse control disorders. To explore the role of the noradrenergic system in pathological gamblers (PG), we assessed neuroendocrine growth hormone (GH) response to the alpha2-adrenergic receptor agonist clonidine and placebo in PG and controls. The net effects of clonidine are a decrease in neurotransmission by depressing locus coeruleus activity and stimulation of GH secretion through activation of post-synaptic alpha2-adrenergic receptors in the hypothalamus. Twenty-nine PG subjects, free of other comorbid conditions, and 27 healthy controls received a double-blinded, placebo-controlled, single dose of oral clonidine (0.15 mg/kg). Data observed included GH, clonidine levels and levels of the main noradrenergic metabolite, 3-methoxy-4-hydroxy-phenylglycol (MHPG). The area under the curve for GH response to clonidine was significantly lower (separate variance t with 44.3 df = 2.626, P = 0.012, d = 0.58) in the PG group (199.6) than in the control group (426.3). PG had significantly blunted GH responses compared with controls at 120 and 150 min post-clonidine. These results are consistent with the idea that the subsensitivity of post-synaptic alpha-2 receptors is possibly attributable to higher-than-normal noradrenergic secretion in PG. This peripheral noradrenergic dysfunction could be consistent with attenuated cortico-frontal noradrenergic function as shown in positron emission tomography (PET) studies of PG.

Italian consensus statement on paediatric HIV infection

The objective of this document is to identify and reinforce current recommendations concerning the management of HIV infection in infants and children in the context of good resource availability. All recommendations were graded according to the strength and quality of the evidence and were voted on by the 57 participants attending the first Italian Consensus on Paediatric HIV, held in Siracusa in 2008. Paediatricians and HIV/AIDS care specialists were requested to agree on different statements summarizing key issues in the management of paediatric HIV. The comprehensive approach on preventing mother-to-child transmission (PMTCT) has clearly reduced the number of children acquiring the infection in Italy. Although further reduction of MTCT should be attempted, efforts to personalize intervention to specific cases are now required in order to optimise the treatment and care of HIV-infected children. The prompt initiation of treatment and careful selection of first-line regimen, taking into consideration potency and tolerance, remain central. In addition, opportunistic infection prevention, adherence to treatment, and long-term psychosocial consequences are becoming increasingly relevant in the era of effective antiretroviral combination therapies (ART). The increasing proportion of infected children achieving adulthood highlights the need for multidisciplinary strategies to facilitate transition to adult care and maintain strategies specific to perinatally acquired HIV infection.

Unilateral low frequency versus sequential bilateral repetitive transcranial magnetic stimulation: is simpler better for treatment of resistant depression?

Repetitive transcranial magnetic stimulation (rTMS) efficacy in the treatment of major depression has been shown in both low frequency right-sided and high frequency left-sided stimulation over the dorsolateral prefrontal cortex (DLPFC). The aim of the present investigation was to evaluate the hypothesis of an additive effect of bilateral stimulation compare to sequential to unilateral stimulation. Sixty patients with treatment-resistant depression were assigned to receive either low-frequency rTMS over the right DLPFC (140 s x 1 Hz) followed by controlateral sham (unilateral group, n=20), low frequency right DLPFC rTMS followed by left DLPFC high frequency rTMS (5 s x 10 Hz) (bilateral group, n=20), or bilateral sham (sham group, n=20) in a 3 weeks double-blind, randomized trial. The primary outcome variable was the score on Hamilton Depression Scale (HAM-D). Low frequency right-sided and sequential bilateral stimulation showed different antidepressant efficacy at 3 weeks and across the full duration of the study, only the unilateral method appearing significantly more effective than sham at the end of the trial, and correlated to the higher percent of remitters (30% of the group vs. 10% -bilateral- and 5% -sham). Unilateral stimulation, but not bilateral, showed higher antidepressant efficacy compared to sham stimulation. The data suggest that right-sided low frequency stimulation may be a first line treatment alternative in resistant depression. To confirm and extend these findings further studies require a longer follow-up period, supported by biological observation and replication.

Non-alcoholic fatty liver disease is associated with left ventricular diastolic dysfunction in essential hypertension

BACKGROUND AND AIM

Insulin resistance is recognized as the pathophysiological hallmark of non-alcoholic fatty liver disease (NAFLD). A relation between insulin sensitivity and left ventricular morphology and function has been reported in essential hypertension, where a high prevalence of NAFLD has been recently found. We investigated the inter-relationship between left ventricular morphology/function, metabolic parameters and NAFLD in 86 never-treated essential hypertensive patients subdivided in two subgroups according to the presence (n = 48) or absence (n = 38) of NAFLD at ultrasonography.

METHODS AND RESULTS

The two groups were similar as to sex, age and blood pressure levels. No patient had diabetes mellitus, obesity, hyperlipidemia, or other risk factors for liver disease. Body mass index, waist circumference, triglycerides, glucose, insulin, homeostasis model of assessment index for insulin resistance (HOMA-IR), aspartate aminotransferase and alanine aminotransferase were higher and adiponectin levels were lower in patients with NAFLD than in patients without NAFLD, and were associated with NAFLD at univariate analysis. Patients with NAFLD had similar prevalence of left ventricular hypertrophy compared to patients without NAFLD, but a higher prevalence of diastolic dysfunction (62.5 vs 21.1%, P < 0.001), as defined by E/A ratio <1 and E-wave deceleration time >220 ms. Diastolic dysfunction (P = 0.040) and HOMA-IR (P = 0.012) remained independently associated with NAFLD at backward multivariate analysis.

CONCLUSIONS

Non-alcoholic fatty liver disease was associated with insulin resistance and abnormalities of left ventricular diastolic function in a cohort of patients with essential hypertension, suggesting a concomitant increase of metabolic and cardiac risk in this condition.

Meningioma and systemic lupus erythematosus: a matter of pure coincidence?

To describe three cases of meningioma observed in a large cohort of 546 patients with systemic lupus erythematosus (SLE) followed at our Department in the last 15 years. We identified three cases of meningioma among 181 patients with SLE who underwent a brain magnetic resonance imaging (MRI) during their disease course (prevalence 1.65%). All three SLE cases were women with a disease onset at 47-, 18- and 42 -years-old, respectively. All patients presented neuropsychiatric (NP) symptoms and had an incidental finding of a meningioma at brain MRI. One patient presented simultaneously a breast cancer. Only one patient had the surgical removal of the mass without improvement of her symptoms while in the other two patients, the removal was not indicated. The association between meningioma and SLE may be a pure coincidence. However, it draws our attention because its detection may represent a confounding factor in the setting of a NPSLE patient.

Low prevalence of selective IgA deficiency in infected children born to HIV-seropositive mothers: an in vivo model for speculation on selective IgA deficiency pathogenesis

Anecdotal reports of restored immunoglobulin production in individuals with common variable immunodeficiency after acquiring HIV infection suggest that perturbation of the immune system occurring during HIV infection may force some underlying functional defects. These findings raise intriguing questions about the pathogenesis of common variable immunodeficiency. No study has investigated the possible influence of HIV infection on the development of selective IgA deficiency, a primary immunologic defect genetically related to common variable immunodeficiency. IgA serum levels were evaluated in a large cohort of children born to HIV-infected mothers from 1985 to 2006. To avoid differences possibly due to different follow-up durations we considered only infected and non-infected children aged over 4 years at last-follow-up. The study included 1,157 non-infected children and 964 infected children, aged ≥ 4 years at last-follow-up and with availability of two or more serum IgA determinations over six months of age. No child displayed immunoglobulin values compatible with diagnosis of common variable immunodeficiency. However, 0/964 infected children vs. 5/1157 non-infected children had selective IgA deficiency (P=0.048). It may be speculated that several immunological alterations, occurring simultaneously in perinatal HIV infection, surpass the functional defect exhibited in some children with selective IgA deficiency. Our data may shed light on the pathogenesis of selective IgA deficiency.

Impact of medically assisted fertility on preterm birth

Preterm birth is a frequent problem in women who undergo treatment for infertility. Many factors appear to contribute to the occurrence of this complication. Infertile women seem to have a predisposition to giving birth preterm and to having low birthweight babies. These complications also occur in women with a history of infertility who achieve pregnancy without treatment and who have singleton pregnancies. Assisted reproduction patients treated with in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) have a disproportionately high occurrence of preterm births even with singleton pregnancies. Spontaneous preterm labour may be related to underlying medical conditions of the female partner, as its occurrence is not increased in subjects treated with ICSI (i.e. when the infertility problem is associated with male reproductive dysfunction in normal female partners). Multiple pregnancy is the factor most likely to be related to preterm birth in infertile women. The administration of drugs to induce ovulation either alone or combined with intrauterine insemination causes a significant increase in multiple pregnancies. The occurrence of higher order multiple pregnancy is also increased. Multiple pregnancy in women undergoing IVF or ICSI is related to the number of embryos transferred at the end of treatment. The transfer of more than two embryos in women under 35 is not associated with an increased chance of conception, while the occurrence of multiple pregnancy is significantly increased. Women over 40 may benefit from the transfer of more than two embryos, with fewer risks of multiple pregnancy. Single embryo transfer is increasingly considered a workable clinical option, particularly in young women. Hopefully, a more cautious approach to infertility management will reduce the occurrence of multiple pregnancy, spontaneous preterm labour and the high number of low birthweight infants born after treating these women.

Herpetic whitlow as a harbinger of pediatric HIV-1 infection

Herpetic whitlow applies to a primary or recurrent herpes simplex infection of the fingers. It is a rare condition in immunocompetent patients, and usually has a rapid evolution and prompt response to treatment. We report a 10-year-old girl referred to our department of infectious diseases with recurrent and unresponsive ulcerated and necrotic lesions of the fingers of both hands as a first sign of human immunodeficiency virus infection. Numerous instances of extensive or recurrent herpes lesions of the mouth, lips, and perianal areas have been found in the literature, but we have not found any report of periungual infection as a first manifestation of human immunodeficiency virus infection. Pediatricians and dermatologists need to be aware of this association in order to make an early diagnosis and start treatment of these patients' disease.

Pharmacokinetics and pharmacodynamics of nelfinavir administered twice or thrice daily to human immunodeficiency virus type 1-infected children

We studied the pharmacokinetics and pharmacodynamics of nelfinavir administered 2 or 3 times per day to human immunodeficiency virus type 1 (HIV-1)-infected children receiving highly active antiretroviral therapy containing nelfinavir. The geometric mean trough concentrations of nelfinavir for the thrice- and twice-daily regimens were 1.55 mg/L and 1.11 mg/L, respectively (P=not significant). Nelfinavir concentrations did not correlate with total daily dose, dose per kilogram of weight, age, weight, previous protease inhibitor (PI) experience, or CD4(+) cell percentage. In the 25 PI-naive children, the virus load reductions at 24 weeks of treatment with the twice- and thrice-daily regimens were comparable. A significantly higher percentage of children in the twice-daily group had a trough concentration of nelfinavir of less than the inhibitory concentration of 95% (P=.042). The decrease in the virus load at 24 weeks of treatment was not correlated with the trough concentration of nelfinavir. The variability of trough concentrations was extremely high, particularly among recipients of the twice-daily regimen, resulting in a higher number of patients with subinhibitory concentrations of nelfinavir in this group.

Serum leptin and CD4+ T lymphocytes in HIV+ children during highly active antiretroviral therapy

OBJECTIVE

Because leptin, the adipocyte-derived hormone, affects thymocyte survival, proliferation of naïve T lymphocytes and the production of proinflammatory cytokines, we aimed to investigate the role of this molecule in immunoreconstitution during highly active antiretroviral therapy (HAART).

DESIGN

Prospective longitudinal cohort study. A series of 20 HIV+ children were studied. The subjects were grouped by their increase in serum leptin levels after HAART.

METHODS

All participants were weight-stable, free of endocrine disorders and opportunistic infections and equally distributed for sex (males, n=10; females, n=10). Body mass index (BMI), serum lipids, leptin, CD4+ T cells and HIV-1 RNA were measured before initiation of HAART and after a 2-year follow-up.

RESULTS

Serum leptin concentration positively correlated with CD4+ lymphocyte number before treatment. HAART significantly reduced viraemia and increased serum levels of lipids in all patients, whereas a significant increase in CD4+ cells and serum leptin was observed in the majority of patients. Notably, in children where HAART was not effective in increasing CD4+ lymphocyte counts, serum leptin did not increase.

CONCLUSION

To our knowledge, these findings reveal for the first time a novel link among CD4+ T lymphocytes, serum leptin and highly active anteretroviral theraphy.

Kinetics of the T-cell receptor CD4 and CD8 V beta repertoire in HIV-1 vertically infected infants early treated with HAART

OBJECTIVES

To determine the kinetics and the relationship between the T-cell receptor V beta (TCRBV) complementary determining region 3 length, the CD4 T-cell count and HIV viral load changes in HIV-1 infected infants treated early with highly active antiretroviral therapy (HAART) during 1 year of follow-up.

DESIGN

Two HIV-1 vertically infected infants, two HIV-1 vertically exposed uninfected and two healthy controls were analysed by spectratyping. Evaluation of viral load, CD4 naive and memory cell counts and a proliferation test were also carried out.

METHODS

Twenty-six families and subfamilies of the TCR on CD4 and CD8 T cells were analyzed by spectratyping. Flow cytometric analysis on peripheral blood mononuclear cells for CD4CD45Ra, CD4CD45Ro, CD8CD38, proliferation tests and plasma viral load measurements were performed at baseline, 1, 6 and after 12 months of therapy.

RESULTS

HAART induced a marked reduction of viral load in both HIV-1 infected infants and an increase to normal CD4 T-cell count in the symptomatic infant. At baseline the TCRBV family distribution in the majority of CD8 and a few of the CD4 T cells was highly perturbed, with several TCRBV families showing a monoclonal/oligoclonal distribution. During HAART a normalization of the TCR repertoire in both CD8 and CD4 subsets occurred. TCR repertoire normalization was associated with a good virological and immunological response.

CONCLUSION

These results suggest that complete and early virus replication control as a result of early HAART leads to a marked reduction of T-cell oligoclonality and is an essential prerequisite to the development of a polyclonal immune response in HIV-1 infected infants.

Discrepancy between polymerase chain reaction assay and Western blot analysis in the assessment of CagA status in dyspeptic patients

BACKGROUND

Infection with CagA-positive Helicobacter pylori may be diagnosed by detecting cagA gene by polymerase chain reaction assay (PCR) or serum antibodies against CagA by Western blot analysis. The aim of this study is to evaluate whether results of PCR and Western blot analysis are in agreement in CagA status assessment.

PATIENTS AND METHODS

Thirty-six dyspeptic patients with unknown H. pylori status underwent upper gastrointestinal endoscopy to assess the presence of mucosal lesions and to collect six gastric biopsies (three from the antrum and three from the body) for evaluation of H. pylori infection (rapid urease test, histology and PCR for ureA gene) and gastritis. CagA status was assessed by PCR (cagA gene) on two biopsy specimens and by Western blot analysis of serum (CagA-antibodies) in each patient.

RESULTS

At endoscopy, nine patients showed normal mucosa, 15 a duodenal ulcer and 12 antral erosions. Twenty-eight patients were found to be H. pylori-positive and eight H. pylori-negative. Of the 28 H. pylori-positive patients, 17 were CagA-positive and five were CagA-negative by both methods, five were CagA-positive by Western blot analysis but not by PCR and one was CagA-positive by PCR but not by Western blot analysis. Of the eight H. pylori-negative patients, none was CagA-positive by PCR, while six were CagA-positive by Western blot analysis. Therefore, the two tests agreed in only 24 patients (67%). In those patients in whom the PCR and Western blot analysis were not in agreement, the histological features appear to suggest that the results of the Western blot analysis should be considered false positives or false negatives.

CONCLUSIONS

PCR and Western blot analysis failed to provide comparable data in many cases. Western blot analysis seems to be more likely to give misleading results than PCR. Thus, PCR seems to be the method of choice to assess CagA status.

[Intraepithelial enteroendocrine cells in cecum and appendix from ovoalbumin sensitized rabbits]

Intraepithelial enteroendocrine cells (IEC) produce peptides which influence motility, secretion and absorption of nutrients. Recently the role of these cells in the immune mucosal system is under study. The aim of the present study was to evaluate the modifications in number of IEC in cecum and appendix from Ovalbumin (OVA) sensitized rabbits. Twenty adult New Zealand rabbits were separated in two groups: Group 1 (G1 = 10) not sensitized normal control. Group 2 (G2 = 10) were sensitized twice intraperitoneally with 70 mg OVA and 30 mg ALUM/ml (aluminium hydroxide). Anti OVA specific IgE was evaluated by means of PCA test (passive cutaneous anaphylaxis). Samples form cecum and appendix were fixed in buffered formaldehyde 10%, paraffin embedded and stained with anti-Chromogranin A for neuroendocrine cells. 400 high power fields were counted in each animal, referred as IEC/100 enterocytes. In cecum surface epithelium and crypt were considered. Surface epithelium, deep crypts and superficial crypts were evaluated in appendix. Results showed in cecum in G1:1,6 IEC/100 enterocytes in surface epithelium and 3/100 in crypts; G2 6 IEC/100 in surface epithelium and 12/100 in crypts. The difference between G1 and G2 was statistically significant (p < 0.05). In appendix surface epithelium from G1 showed 5.2/100 while G2 5.4/100. Superficial crypts 8.5 (G1) and 11.3 (G2) (p < 0.05) and deep crypts 4.9 (G1) and 8.5 (G2) (p < 0.01). The results showed that OVA-sensitized animals presented increment in the number of IEC in surface epithelium and crypts which may indicate a relationship between these cells and rabbit mucosal immune system.

Variable use of therapeutic interventions for children with human immunodeficiency virus type 1 infection in Europe

Although a range of antiretroviral drugs are available for use in children, the appropriate paediatric regimen remains unclear. In a survey to investigate policies and practices relating to the therapeutic management of children infected by the human immunodeficiency virus (HIV), a postal questionnaire was sent to a named paediatrician in 70 major HIV centres in 13 European countries in early 1998. A total of 64 paediatricians (91%) responded. Pneumocystis carinii pneumonia prophylaxis was found to be routine in all centres, although considerable variation existed regarding the time of starting and stopping therapy. Prophylaxis for fungal infections and recurrent bacterial infections was common, with cytomegalovirus prophylaxis being less frequent. Although most centres (89%) used all five currently available nucleoside analogues (ziduvodine, lamivudine, stavudine, didanosine, zalcitabine), there was considerable variability regarding the availability of protease inhibitors. Most respondents delayed initiation of antiretroviral therapy until evidence of disease progression was apparent. The initial prescription of 38% of clinicians was triple therapy and that of 57% prescribed double therapy. Policies varied regarding the modification to regimens in response to disease progression and emergence of side effects and drug resistance. Clinical practice was informed by a number of sources, including centre-specific and national guidelines. Most respondents affirmed the need for European guidelines.

CONCLUSION

Approaches to the therapeutic management of paediatric human immunodeficiency virus infection differ across Europe.

[Digital pacinian hyperplasia. Report of a case associated with foreign body reaction]

Digital Pacinian Hyperplasia is a non tumoral, very rare lesion. To date, only 31 cases have been reported, occasionally named Digital Pacinian Neuroma. Digital pain is usually associated to. Local trauma is reported in about half of the cases. We report a new case occurred in a 62 year-old male, associated with inflammatory and foreign body reaction. No recurrence was observed 6 months after surgical excision. Differential diagnosis and controversies about this lesion are discussed.

Mucocutaneous manifestations in children with HIV infection and AIDS

Mucocutaneous diseases are more frequent in HIV/AIDS-infected children than in the normal population. We analyze mucocutaneous disorders with atypical presentations in a large population of HIV-infected children, with or without full-blown AIDS, compared to a population of HIV seroreverted children. The majority of these cutaneous disorders have an infectious etiology and their frequency is related to the degree of deterioration of the immune system. Some diseases commonly observed in adults are rare in children; neoplasms are an exception.