A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

B-05 Age of Seizure Onset Predicted Categorical Fluency Switching and Anxiety in People with Temporal Lobe Epilepsy

Objective

To examine whether demographic variables can assist in predicting executive dysfunction in individuals with temporal lobe epilepsy (TLE).

Method

Data were collected from presurgical evaluations of 13 individuals with TLE (67% females, mean age 34 ± 12) at the University of California, San Francisco Epilepsy Center. Executive functions were assessed using subtests from the D-KEFS (Verbal Fluency and Color/Word Interference Tests) and the Trail Making Test B. Given that depression and anxiety symptoms have been previously shown to be associated with poorer executive performance in individuals with TLE (Paradiso et al., 2001), predictability of the BDI-II and BAI scores were also tested. Linear regression analyses were used to test predictive values of demographic variables (age, age at seizure onset [ASO], years of education, gender, and right vs. left temporal epileptogenic source).

Results

ASO (β = .75, p = .021), gender (β = .632, p = .041), and education (β = .555, p = .05) explained 66% of the variance in the Verbal Fluency Switching scaled scores (R²=.66, F(4,8)= 3.876, p = .049). Education (β = .772, p = .009) and ASO (β = .686, p = .023) explained 70% of the variance in Verbal Fluency Switching Accuracy scaled scores (R² = .708, F(4,8) = 4.844, p = .028). Age (β = -.862, p = .003) and seizure onset (β = .457, p = .049) explained 52% of the variance in BAI scores (R² = .525, F(4,16) = 3.319, p = .032).

Conclusions

ASO predicted category switching and anxiety severity, while none of the demographic variables explored in this study predicted visuomotor switching. Further research should explore the efficacy of early interventions to protect against future executive dysfunction in TLE.

The impact of immunoglobulin in acute HIV infection on the HIV reservoir: a randomized controlled trial

OBJECTIVES

Antiretroviral therapy (ART) during acute HIV infection (AHI) restricts the HIV reservoir, but additional interventions are necessary to induce a cure. Intravenous immunoglobulin (IVIG) is not HIV-specific but is safe and temporarily reduces the HIV reservoir in chronic HIV infection. We present a randomized controlled trial to investigate whether IVIG plus ART in AHI reduces the HIV reservoir and immune activation compared with ART alone.

METHODS

Ten men with AHI (Fiebig II-IV) initiated ART (tenofovir, entricitabine, ritonavir boosted darunavir and raltegravir) at HIV-1 diagnosis and were randomized to ART alone or ART plus 5 days of IVIG, once virally suppressed (week 19). Blood samples were evaluated for viral reservoir, immune activation, immune exhaustion and microbial translocation. Flexible sigmoidoscopy was performed at weeks 19, 24 and 48, and gut proviral DNA and cell numbers determined.

RESULTS

IVIG was well tolerated and no viral blips (> 50 HIV-1 RNA copies/mL) occurred during IVIG therapy. From baseline to week 48, total HIV DNA in peripheral blood mononuclear cells (PBMCs) (cases: -3.7 log₁₀ copies/10⁶ CD4 cells; controls: -3.87 log₁₀ copies/10⁶ CD4 cells) declined with no differences observed between the groups (P = 0.49). Declines were observed in both groups from week 19 to week 48 in total HIV DNA in PBMCs (P = 0.38), serum low copy RNA (P = 0.57) and gut total HIV DNA (P = 0.55), but again there were no significant differences between arms. Biomarkers of immune activation, immune exhaustion and microbial translocation and the CD4:CD8 ratio were similar between arms for all comparisons.

CONCLUSIONS

Although safe, IVIG in AHI did not impact total HIV DNA, immune function or microbial translocation in peripheral blood or gut tissue.

Music interventions for dental anxiety

Anxiety is a significant issue in the dental care of adults and children. Dental anxiety often leads to avoidance of dental care which may result in significant deterioration of oral and dental health. Non-pharmacological anxiety management interventions such as music listening are increasingly used in dental care. Although efficacy for music's anxiolytic effects has been established for pre-operative anxiety, findings regarding the use of music listening for dental anxiety are inconclusive, especially for children. The use of music for passive distraction may not be adequate for children and highly anxious adults. Instead, interventions offered by a trained music therapist may be needed to optimize music's anxiolytic impact. Music therapy interventions are individualized to the patient's presenting needs and geared at enhancing patients' active engagement in the management of their anxiety. Interventions may include (i) active refocusing of attention, (ii) music-guided deep breathing, (iii) music-assisted relaxation, and (iv) music-guided imagery. In addition, music therapists can teach patients music-based anxiety management skills prior to dental treatments, offer them the opportunity to express emotions related to the upcoming procedure, and help them gain a sense of control and safety. Clinical guidelines for the use of music listening by dental practitioners are offered.

Calvarial syphilis in an HIV-positive man

Bone involvement in secondary and tertiary syphilis is a well-documented but unusual phenomenon. We report the case of an atypical presentation of secondary syphilis in a 25-year-old HIV-positive man who has sex with men. He presented initially with headaches and an unusual calvarial swelling. The skull findings were consistent with osteitis and he later developed systemic symptoms. Treponema pallidum serology was positive and the lesions and systemic symptoms resolved completely after administration of appropriate antibiotic therapy.

CD8 count measurement has independent prognostic significance in individuals with AIDS-Kaposi sarcoma

20500

Background: We recently published a prognostic index for Acquired Immunodeficiency Syndrome (AIDS)-associated Kaposi sarcoma (KS) diagnosed in the era of highly active antiretroviral therapy (HAART) based on clinical and routine laboratory characteristics. Because immune subset measurement is often performed in human immunodeficiency virus (HIV) positive individuals, we examined whether these were predictive of mortality independently of the prognostic index, or could predict time to progression of KS. Methods: We performed univariate and multivariate Cox regression analyses on a dataset of 326 individuals with AIDS-KS to identify immune subset covariates predictive of overall survival and time to progression. Adaptive (CD8 T cell and CD19 B cell) and innate (CD16/56 natural killer cell) immune parameters were studied by flow cytometry. Results: In univariate analyses all 3 immune subsets had significant effects on overall survival (p < 0.025). In multivariate analyses including the prognostic index, only CD8 counts remained significant (p = 0.026) although its effect on the overall prognostic index is small. An increase of 100 cells/mm3 in the CD8 count confers a 5% improvement in overall survival. Individuals with a higher CD8 count did not have an increased time to progression. Patients who were already on HAART at the time of KS diagnosis did not have a shorter time to progression than those who were antiretroviral naïve at KS diagnosis. Conclusions: The CD8 count appears to provide independent prognostic information in individuals with AIDS-KS. Measurement of the CD8 count is clinically useful in patients with KS.

No significant financial relationships to disclose.

Prospective cohort study showing changes in the monthly incidence of Pneumocystis carinii pneumonia

Pneumocystis carinii pneumonia (PCP) remains a serious opportunistic infection in HIV infected individuals. Seasonal changes in climate are associated with changes within individual susceptibility to infection. The possibility of monthly variability in the incidence of PCP was therefore examined by means of a cohort study of a database of 8640 HIV infected individuals attending the Chelsea and Westminster Hospital. There were 792 cases of PCP diagnosed since 1985. A marked decline was observed in the incidence of PCP in mid-1992 coincident with the introduction of PCP prophylaxis. There was a further decline in 1996 after the introduction of highly active antiretroviral therapy. Despite no significant monthly variation in the mean attendance to clinic and CD4 count, both new and all cases of PCP were higher in January than in other months (15.9% and 14.5% of all cases, respectively). A correlation with low rainfall in January and new cases of PCP was observed. These data are consistent with an influence of climatic conditions on the presentation of PCP. The diagnosis of PCP is more common in winter months suggesting that this is a transmissible infection.

Frey's syndrome following submandibular gland excision: an unusual postoperative complication

Gustatory sweating and flushing, or Frey's syndrome, is a fairly common complication following surgery or injury to the parotid gland and is thought to be caused by aberrant nerve regeneration. A similar condition has been reported in the literature following surgery to the submandibular region. Since this was first described in 1934, only 7 subsequent cases of submandibular sweating and flushing have been reported. We present a case of a 52-year-old female who underwent excision of the left submandibular gland as a result of chronic sialadenitis. Twelve months following surgery, symptoms indicative of Frey's syndrome were experienced in the operative region. A review of the aetiology and treatment of the condition is described.

Transmission of retroviruses from seronegative donors by transfusion during cardiac surgery. A multicenter study of HIV-1 and HTLV-I/II infections

OBJECTIVE

To evaluate the effectiveness of serologic testing of blood donors for human immunodeficiency virus type 1 (HIV-1) and human T-cell lymphotropic virus types I and II (HTLV-I/II) infections and to estimate the risk for transmission of HIV-1 and HTLV-I/II by transfusion of seronegative blood from screened donors.

DESIGN

A prospective multicenter cohort study of cardiac surgery patients who received multiple transfusions between 1985 and 1991.

SETTING

Cardiac surgery services of three large tertiary care hospitals.

PATIENTS

The study included 11,532 patients in three hospitals who had cardiovascular surgery.

MEASUREMENTS

Incident HIV-1 and HTLV-I or HTLV-II infection.

RESULTS

We detected two new HIV-1 infections among patients transfused with 120,312 units of blood components from seronegative donors. In each case a donor was detected on follow-up who had seroconverted since the donation. The HIV-1 infection rate was 0.0017% with an upper limit of the 95% CI of 0.0053%. Before donor screening for HTLV-I, transfusion of 51,026 units resulted in two HTLV-I infections (0.0039%) and four HTLV-II infections (0.0078%). After HTLV-I screening was instituted, one recipient was infected with HTLV-II among participants exposed to 69,272 units, a rate of 0.0014%. A corresponding HTLV-I/II-infected donor was found for this patient.

CONCLUSION

Serologic screening of donors for antibodies to HIV-1 and HTLV-I coupled with exclusion of donors from groups having a relatively high risk for infection has led to a low incidence of transfusion-transmitted HIV-1 and HTLV-I/II infection in the United States. A small risk remains, however, despite these measures. We estimate the residual risk for HIV-1 and HTLV-II infection from transfusion of screened blood during the time of this study to be about 1 in 60,000 units.