Retrospective analysis of antiretroviral HIV treatment success based on medical history or guided by the reverse hybridisation LiPA HIV genotyping system

The changes in viral load and CD4(+) count at 3 and 6 months in a group of 166 HIV-infected patients was evaluated. The new therapy was chosen based on the medical history procedures for 70 patients, and in 96 patients it was guided by the partial or complete result of the line probe assay (LiPA) HIV RT and Protease resistance tests. The absolute difference from the baseline of the log viral load at 3 and 6 months was significantly different between the two groups when adjusted for baseline viral load (P < 0.0001) and stayed significant when intention-to-treat analysis was carried out (P < 0.001). The absolute difference of the CD4(+) count was not significantly different when adjusted for baseline CD4(+) (P = 0.854, 3 months; P = 0.06, 6 months). The proportion of patients with a viral load </=200 cp/ml in the medical history group (14.5%, 3 months; 15.2%, 6 months) was significantly different from the proportion of responders in the LiPA group (28.7%, 3 months, P = 0.03; 34.7%, 6 months, P = 0.008). In the intention-to-treat population, the difference between the two groups remained significant (P = 0.01). There was no statistical difference between the two groups in terms of adherence (P = 0.88), number of drug failures (P = 0.12) and for the time since starting treatment (in years) (P = 0.48), but there was a significant difference for the number of new drugs in the new regimen (P < 0.0001) and for the pill burden of the treatment (P = 0.0006). A higher antiretroviral HIV treatment success guided by the LiPA HIV genotyping system than that based on the medical history only is reported. Of note, this study reached the same conclusions as previous studies, which all used sequencing.

Early diagnosis of candidiasis in non-neutropenic critically ill patients

OBJECTIVE

To determine a method for the early diagnosis of candidiasis in non-neutropenic critically ill patients in order to reduce mortality.

METHODS

A prospective study in non-neutropenic critically patients in whom Candida spp. were detected, was made in an intensive care unit (ICU) during an 8-year period from 3389 patients admitted. A diagnostic and therapeutic protocol was designed. Invasive candidiasis was defined according to dissemination and multifocality.

RESULTS

Candida spp. were found in 145 cases (4.3%): 120 (83%) were considered as invasive candidiasis and 25 as colonisation (17%). The hospital mortality was 46% (67/145). A post-mortem study was carried out in 54% (36/67) of hospital deaths. Candida albicans was the most frequently isolated species (87%), followed by Candida glabrata (18%). There were 24 candidemias and three cases of endophtalmitis. Digestive and respiratory samples and non-C. albicans yeasts were risk factors for invasive candidiasis. The mortality rate was related statistically to invasive candidiasis and inversely to the appropriate antifungal treatment.

CONCLUSIONS

Invasive candidiasis is related to digestive and respiratory samples and to the presence of non-C. albicans species. A simpler definition of invasive candidiasis in non-neutropenic critically ill patients will permit more rapid and accurate specific antifungal therapy.

[Diabetes mellitus and pancreatic tumor]

A 68 year old Ecuadorian man was investigated for polyuria, polydipsia and weight loss of 3 kg during the previous two months. Insulin dependent diabetes mellitus was diagnosed 10 year before admission and treated with appropriate diet and insulin (35 U/d). 18 months before was diagnosed in El Ecuador of "multiple liver nodes non-suggestive of malignancy". Physical examination showed a large multinodular petrous hepatomegaly. There was no evidence of skin lesions. Results of laboratory studies included a basal plasma glucose level that ranged between 275-367 mg/dl (N=60-100), glycosylated haemoglobin of 8.9% (N<5) and a serum albumin of 2.8 gr./dl (N=3.4-4.8). At admission non-other laboratory alterations were detected. Computed tomography showed a mass on the head of the pancreas with loco-regional lymph nodes and liver metastases. Tumor markers were normal. Fine-needle aspiration cytology of the liver masses revealed the presence of liver metastases of a non-differentiated malignant tumor. A 111In-DTPAOC scintigraphy revealed the presence of somatostatin receptors in the liver metastases, also detecting the presence of multiple bone metastases in the axial and appendicular skeleton. Plasma glucagon level was 678 pg/ml (N<250). A diagnosis of metastatic glucagonoma was established and therapy with streptozocin, 5-FU, insulin and synthetic somatostatin analogs was initiated. Three months after the therapy initiation the patient was symptom free. Some weeks after the patient suffered from left hip pain, and a control 111In-DTPA scintigraphy showed progression of his bone metastases. In conclusion, glucagonoma must be suspected in all diabetic patients with metastatic liver, even in absence of necrotic migratory erythema. In these circumstances, plasmatic glucagon level and somatostatin receptors scintigraphy will be a useful tool for establishing the final diagnosis.

[Somatostatin receptor scintigraphy. When would a SPECT study be performed?]

Somatostatin receptor scintigraphy has become an essential tool in the treatment planning of patients with carcinoid tumor (CaT) and pancreatic neuroendocrine tumors (PNET). However, the contribution of SPECT images in the diagnosis and staging of these tumors has not been well established.

OBJECTIVE

1) To find out if SPECT improves the sensitivity of planar imaging and adds any value to tumor diagnosis, and 2) To determine under which circumstances SPECT images must be obtained.

MATERIAL AND METHODS

We have evaluated 49 patients, 26 females and 23 males, using both planar and SPECT 111In-DTPAOC images. The patients were classified into three groups according to their clinical indication: Group A: Indolent symptoms of CaT or PNET (n = 9); Group B: Known or functioning CaT or PNET tumors (n = 22); Group C: Post-surgical follow-up (n = 18). The total number of SPECT studies were 51 (37 abdomen, 13 thorax and 1 brain). In all cases SPECT was performed 24 hours after 111In-DTPAOC injection. Scintigraphic images were compared with surgical findings in 17 patients and with a synthesis of biochemical, clinical and CT findings in the other patients.

RESULTS

16 primary lesions were detected with planar images whereas SPECT detected 18. The two tumors detected only by SPECT were a bronchial CaT and an insulinoma located in the pancreatic tail. Planar and SPECT image sensitivities were 66.6% and 75% respectively. Twenty one patients developed metastatic disease. Sensitivities of planar and SPECT images for metastases were 76.1% and 90.4% respectively. Furthermore, SPECT helps planar images in the evaluation of six patients with uncertain images (lesions with low receptor density or with an uncertain scintigraphic localization). Therefore, in 15.6% of patients with primary or metastatic tumors, planar images were normal whereas SPECT was abnormal and SPECT provided an added value in 21.8% of the studies with abnormal planar images.

CONCLUSIONS

We recommend the use of SPECT images in: 1) Patients with specific functional clinical syndrome or with a known CaT or PNET and normal planar images. 2) When planar images are abnormal only in primary tumor. 3) In order to confirm the absence of other metastases in patients with known liver metastases. 4) In order to enhance the detection of lesions with low receptor density and uncertain planar images and 5) In order to determine exactly the anatomic location of some lesions

A nosocomial outbreak of influenza during a period without influenza epidemic activity

The objective of this study was to describe a nosocomial outbreak of influenza during a period without influenza epidemic activity in the community. Outbreak investigation was carried out in an infectious diseases ward of a tertiary hospital. Presence of two or more of the following symptoms were used to define influenza: cough, sore throat, myalgia and fever. Epidemiological survey, direct immunofluorescence, viral culture, polymerase chain reaction, haemagglutination-inhibition test in throat swabs and serology for respiratory viruses were performed. Twenty-nine of 57 healthcare workers (HCW) (51%) and eight of 23 hospitalised patients (34%) fulfilled the case definition. Sixteen HCW (55%) and three inpatients (37%) had a definitive diagnosis of influenza A virus infection (subtype H1N1). Among the symptomatic HCW, 93% had not been vaccinated against influenza that season. Affected inpatients were isolated and admissions in the ward were cancelled for 2 weeks. Symptomatic HCW were sent home for 1 week. On the seventeenth day of the outbreak the last case was declared. The incidence of cases in this outbreak of influenza, which occurred during a period without influenza epidemic activity in the community, was notably high. Epidemiological data suggest transmission from healthcare workers to inpatients. Most healthcare workers were not vaccinated against influenza. Vaccination programmes should be reinforced among healthcare workers.

Effects of L-741,741, a selective dopamine receptor antagonist, on anxiety tested in the elevated plus-maze in mice

Dopamine systems are involved in modulation of anxiety. Although the action of D1/5, D2 and D3 receptor antagonists on anxiety has been documented in different animal models, little is known about the influence of D4 dopamine antagonists. The aim of this study was to examine the effects of L-741,741 (0.75, 1.5 and 3 mg/kg i.p.), a selective D4 dopamine receptor antagonist, on anxiety tested in the elevated plus-maze. Forty-eight albino adult male mice of the OF.1 strain were used. Animals were randomly allocated to one control group receiving physiological saline and dymethyl-sulphoxide (DMSO) (10%) and three experimental groups receiving L-741,741 injections. Tests were performed 30 min after injections for a duration of 5 min. A number of classical parameters were collected: i) open arm duration; ii) closed arm duration; iii) central platform duration; iv) open arm frequency; v) closed arm frequency; vi) central platform frequency; and vii) number of rearings. L-741,741 did not produce any significant behavioral changes under present test conditions, suggesting that the dopamine D4 receptor might not be involved in the modulation of anxiety-related behaviors in the plus-maze.

Histopathologic and histochemical characterization of calcified structures in hamsters inoculated with Paracoccidioides brasiliensis

In pathogenicity studies of 31 Paracoccidioides brasiliensis isolates preserved using Castellani's method we intraperitoneally inoculated 104 young adult hamsters and found laminated concentric structures and calcified appearance that resembled Schaumann bodies, in 43 of them, especially in animals with apparently good condition. We characterized these structures histologically and histochemically using different stains (PAS, Grocott, haematoxylin-eosin, Von Kossa). The Von Kossa staining revealed calcium in these structures. Similar structures have been described in patients with sarcoidosis and also in hamsters inoculated with P. brasiliensis. We found no correlation between the presence of these calcifications and serum calcium levels.

Identification and characterization of the peptidic component of the immunomodulatory glycoconjugate Immunoferon

Inmunoferon is a glycoconjugate of natural origin, formed by the noncovalent association of a protein from Ricinus communis and a polysacharidic moiety, and endowed with immunomodulatory as well as pharmacological activities. This study investigated the nature of polypeptidic component of Inmunoferon. Through biochemical procedures and comparison with protein databases, the isolated protein was identified as the processed form of the seed of Ricinus communis 2S storage polypeptide, which has been termed RicC3. Further analysis of the isolated protein has revealed that it is composed of two different subunits, alpha and beta, which form an heterodimer of high stability and resistance to denaturation, acidic pH and proteolytic cleavage. These findings confirm the excellent properties of the product after oral administration and provide additional support for the pharmacological activities of Inmunoferon.

Neonatal pemphigus vulgaris with extensive mucocutaneous lesions from a mother with oral pemphigus vulgaris

The clinical phenotype of pemphigus is well explained by the combination of desmoglein (Dsg) 1 and Dsg3 distribution pattern and antiDsg autoantibody profile (Dsg compensation theory). It has been reported that neonatal skin has a similar Dsg distribution pattern to adult mucosal epithelia. We describe a newborn girl with mucocutaneous pemphigus vulgaris (PV) from a mother with mucosal dominant PV. The mother had had painful oral erosions for at least 7 months. Histopathological examination and direct and indirect immunofluorescence studies confirmed the diagnosis of PV and neonatal PV in the mother and daughter, respectively. The mother had a high titre of anti-Dsg3 IgG and a low titre of antiDsg1 IgG, while the neonate had only a high titre of anti-Dsg3 IgG, but no detectable antiDsg1 IgG. AntiDsg3 IgG, which caused the oral dominant phenotype in the mother, induced extensive oral as well as cutaneous lesions in the neonate. Our case provides clinical evidence for the Dsg compensation theory in neonatal PV.

Fragile sites in human and Macaca fascicularis chromosomes are breakpoints in chromosome evolution

We have analysed the expression of aphidicolin-induced common fragile sites at two different aphidicolin concentrations (0.1 micromol/L and 0.2 micromol/L) in three female and one male crab-eating macaques (Macaca fascicularis, Cercopithecidae, Catarrhini). A total of 3948 metaphases were analysed: 1754 in cultures exposed to 0.1 micromol/L aphidicolin, 1261 in cultures exposed to 0.2 micromol/L aphidicolin and 933 in controls. The number of breaks and gaps detected ranged from 439 in cultures exposed to 0.1 micromol/L aphidicolin to 2061 in cultures exposed to 0.2 micromol/L aphidicolin. The use of a multinomial FSM statistical model allowed us to identify 95 fragile sites in the chromosomes of M. fascicularis, of which only 16 are expressed in all four specimens. A comparative study between the chromosomes of M. fascicularis and man has demonstrated that 38 human common fragile sites (50%) are found in the equivalent location in M. fascicularis. The analysis of the rearrangements that have taken place during chromosome evolution has revealed that the breakpoints involved in these rearrangements correspond significantly (p < 0.025) to the location of M. fascicularis fragile sites.

Chromosomal homologies between Cebus and Ateles (primates) based on ZOO-FISH and G-banding comparisons

ZOO-FISH (Fluorescent "in vitro" hybridization) was used to establish the chromosomal homology between humans (HSA) and Cebus nigrivitatus (CNI) and Ateles belzebuth hybridus (ABH). These two species belong to different New World monkey families (Cebidae and Atelidae, respectively) which differ greatly in chromosome number and in chromosome morphology. The molecular results were followed by a detailed banding analysis. The ancestral karyotype of Cebus was then determined by a comparison of in situ hybridization results, as well as chromosomal morphology and banding in other Platyrrhini species. The karyotypes of the four species belonging to the genus Cebus differ from each other by three inversions and one fusion as well as in the location and amounts of heterochromatin. Results obtained by ZOO-FISH in ABH are in general agreement with previous gene-mapping and in situ hybridization data in Ateles, which show that spider monkeys have highly derived genomes. The chromosomal rearrangements detected between HSA and ABH on a band-to-band basis were 27 fusions/fissions, 12 centromeric shifts, and six pericentric inversions. The ancestral karyotype of Cebus was then compared with that of Ateles. The rearrangements detected were 20 fusions/fissions, nine centromeric shifts, and five inversions. Atelidae species are linked by a fragmentation of chromosome 4 into three segments forming an association of 4/15, while Ateles species are linked by 13 derived associations. The results also helped clarify the content of the ancestral platyrrhine karyotype and the mode of chromosomal evolution in these primates. In particular, associations 2/16 and 5/7 should be included in the ancestral karyotype of New World monkeys.

Distribution of intrachromosomal telomeric sequences (ITS) on Macaca fascicularis (Primates) chromosomes and their implication for chromosome evolution

The intrachromosomal location of the telomeric sequence in the crab-eating macaque, Macaca fascicularis (F. Cercopithecidae, Catarrhini) has been analysed by fluorescent in situ hybridisation with a long synthetic (TTAGGG)(n) probe. A total of 237 metaphases was analysed. As expected, all telomeres hybridised with the probe and 90 intrachromosomal loci with different hybridisation frequencies were also detected. The chromosomal location of interstitial telomeric sequences in M. fascicularis and in Homo sapiens was then compared, 37 sites (41.11%) being found to be conserved. Some of these sequences can be derived from rearrangements, such as inversions (MFA13q23) or fusions (MFA2p13 and MFA13p12), that have taken place during karyotype evolution.

[Prolonged clinical pattern of brain death in patients under barbiturate sedation: usefulness of transcranial Doppler]

INTRODUCTION

Throughout the world, is fully accepted that a person is dead when brain death exists. In most situations, neurological criteria permit the diagnosis of brain death, but in some instances, as when high-dose barbiturate therapy has been used, confirmatory testing are required by law.

CLINICAL CASE

We report the case of a 17 year-old women who suffered high-dose barbiturate therapy due to post traumatic intracranial hypertension. During the period of the barbiturate infusion and until six days after the suppression of this therapy, neurological exploration and EEG findings seem to confirm brain death, while transcranial Doppler (TCD) study remained normal.

CONCLUSIONS

TCD is a fast, simple and accurate confirmatory testing in the determination of brain death and its findings are not affected by high-dose barbiturate therapy. We think that TCD must be present in all hospitals where mechanical ventilation and support of patients are carried out.

Freezing protects against allergy to Anisakis simplex

BACKGROUND

Allergic reactions to Anisakis simplex have been described following ingestion of fish and were thought to be possible even if seafood is frozen or well-cooked.

OBJECTIVE

This study aimed to confirm, by challenge test, that dead A. simplex larvae are not able to trigger allergic reactions in patients with proven hypersensitivity to this parasite.

METHODS

Simple-blind, placebo-controlled, oral challenge tests with frozen A. simplex larvae were performed in 12 patients who had suffered severe anaphylactic reactions after ingestion of seafood and diagnosed of A. simplex hypersensitivity by skin prick test and specific IgE. If no reaction appeared, they were told to eat frozen seafood. 63 patients who had suffered urticaria or urticaria/angioedema by demonstratred hypersensitivity to A. simplex were also advised to eat frozen seafood. All of them were reevaluated 6 months later.

RESULTS

All patients tolerated the dead larvae challenge test. After eating previously frozen seafood at least two times per week, all patients, including those who had suffered anaphylactic reactions and those who had only presented cutaneous manifestations, remained asymptomatic.

CONCLUSIONS

Anisakis simplex-allergic patients tolerate ingestion of dead larvae. It is probable that these patients can eat frozen fish and that a seafood-free diet is not necessary.

Development of a new cyclosporine formulation based on poly(caprolactone) microspheres

The present study describes the development of a new cyclosporine formulation based on polycaprolactone (PCL) microspheres (MS) prepared by the solvent evaporation method. Ternary phase diagrams were used to identify the domains where MS were formed. The application of central composite designs established the influence of several technological (stirring speed) and formulation factors (polymer and surfactant amounts, and organic solvent volume) on the size of PCL MS. Cyclosporine-loaded MS of a size around 2.5 microm were prepared and characterized. The stability of the systems, either alone or loaded with cyclosporine, stored at 8 degrees C and room temperature (RT) was assessed as well. Freeze-drying was evaluated as an alternative method to achieve long-term stability. The experimental design showed that the stirring speed and the organic phase volume were the only parameters significantly affecting the MS size. Experimental conditions selected to obtain CyA-loaded MS of 2.5 microm resulted in a high entrapment percentage (98.4 +/- 0.66%) with the drug dissolved or molecularly dispersed within the dense polymeric matrix of MS. After 12 months of storage at 8 degrees C and RT, PCL MS remained physically stable, although the crystallinity of the polymer increased by 35% upon storage at both temperatures. Freeze-drying studies revealed that MS could be successfully lyophilized in the absence of cryoprotectants without significant changes of the drug entrapment; however, the presence of at least 5% cryoprotectant was essential to keep the initial particle size. Therefore, a stable MS-based CyA formulation was easily prepared and characterized. This formulation offer the possibility of CyA administration through different routes.