Bone mineral density among children living with HIV failing first-line anti-retroviral therapy in Uganda: A sub-study of the CHAPAS-4 trial

BACKGROUND

Children living with perinatally acquired HIV (CLWH) survive into adulthood on antiretroviral therapy (ART). HIV, ART, and malnutrition can all lead to low bone mineral density (BMD). Few studies have described bone health among CLWH in Sub-Saharan Africa. We determined the prevalence and factors associated with low BMD among CLWH switching to second-line ART in the CHAPAS-4 trial (ISRCTN22964075) in Uganda.

METHODS

BMD was determined using dual-energy X-ray Absorptiometry (DXA). BMD Z-scores were adjusted for age, sex, height and race. Demographic characteristics were summarized using median interquartile range (IQR) for continuous variables and proportions for categorical variables. Logistic regression was used to determine the associations between each variable and low BMD.

RESULTS

A total of 159 children were enrolled (50% male) with median age (IQR) 10 (7-12) years, median duration of first -line ART 5.2(3.3-6.8) years; CD4 count 774 (528-1083) cells/mm3, weight-for-age Z-score -1.36 (-2.19, -0.65) and body mass index Z-score (BMIZ) -1.31 (-2.06, -0.6). Low (Z-score≤ -2) total body less head (TBLH) BMD was observed in 28 (18%) children, 21(13%) had low lumbar spine (LS) BMD, and15 (9%) had both. Low TBLH BMD was associated with increasing age (adjusted odds ratio [aOR] 1.37; 95% CI: 1.13-1.65, p = 0.001), female sex (aOR: 3.8; 95% CL: 1.31-10.81, p = 0.014), low BMI (aOR 0.36:95% CI: 0.21-0.61, p<0.001), and first-line zidovudine exposure (aOR: 3.68; 95% CI: 1.25-10.8, p = 0.018). CD4 count, viral load and first- line ART duration were not associated with TBLH BMD. Low LS BMD was associated with increasing age (aOR 1.42; 95% CI: 1.16-1.74, p = 0.001) and female sex: (aOR 3.41; 95% CI: 1.18-9.8, p = 0.023).

CONCLUSION

Nearly 20% CLWH failing first-line ART had low BMD which was associated with female sex, older age, first-line ZDV exposure, and low BMI. Prevention, monitoring, and implications following transition to adult care should be prioritized to identify poor bone health in HIV+adolescents entering adulthood.

Severe sequence-specific toxicity when capecitabine is given after Fluorouracil and leucovorin

PURPOSE

Options for single-agent fluoropyrimidine adjuvant therapy after bowel cancer resection include intravenous fluorouracil with leucovorin (FU/LV) or oral capecitabine. These treatments have similar efficacy but differ in convenience and toxicity. We therefore wished to compare their overall acceptability to patients.

PATIENTS AND METHODS

Patients scheduled for adjuvant single-agent fluoropyrimidine therapy were randomly assigned to receive once-weekly FU/LV (425 mg/m(2) FU, 45 mg LV) for 6 weeks, followed by two 3-week cycles of capecitabine (1,250 mg/m(2) twice daily, days 1 through 14), or the same treatments but in reverse order. After 12 weeks, the patients were asked which treatment they preferred, and received the preferred treatment for an additional 12 weeks. The primary end point was patient preference.

RESULTS

After 40 of the planned 74 patients had been randomly assigned, real-time adverse event monitoring led to early trial closure because of excess sequence-specific toxicity. Eleven of 14 patients (79%) receiving capecitabine as their second treatment experienced grade >/= 3 toxicity. This compared with five of 18 patients (28%) receiving capecitabine as the first treatment, and no patients receiving FU/LV as the first treatment (zero of 16) or the second treatment (zero of 12). Similar imbalances were seen in the proportion of patients requiring interruption of treatment.

CONCLUSION

In chemotherapy-naïve patients, capecitabine produced more toxicity than FU/LV, but at levels in line with previously reported data. However, treatment with capecitabine after FU/LV caused markedly increased toxicity, indicating a sequence-specific interaction. The mechanism has not been determined, but interaction with intracellularly retained folate after FU/LV therapy is a possibility. Oncologists need to be aware of this risk if considering crossing patients over from FU/LV to capecitabine-based regimens.

Human cystic and alveolar echinococcoses as indication to liver transplantation

The human cystic and alveolar echinococcoses are zoonotic diseases caused by larval stages of the tapeworms Echinococcus granulosus and E multilocularis. In man the liver form of the diseases develops most frequently. Recent epidemiological data indicate that the distribution of E multilocularis in the central Europe is wider than was previously anticipated; more cases of human alveococcosis during the last years have also been noted in Poland. In the present paper we analyzed several cases of human echinococcoses from Poland with respect to diagnosis and treatment as well as the indications for liver transplantation.

Liver cystadenocarcinoma--case report

A 69-year-old woman was admitted to our Department with the diagnosis of liver cyst. She had previously undergone liver cyst fenestration 10 years before. After abdominal spiral CT, the patient was qualified for laparotomy. A cystic formation was localized in the central part of the liver, in the 4th segment and was found to compress the hilar bile ducts. A 4.5 bisegmentectomy was performed. During the postoperative course, a biliary fistula was observed, which resolved spontaneously. The treatment was also complicated by myocardial infarction. The patient was discharged in good condition 30 days postoperatively. The pathological diagnosis revealed cystadenocarcinoma.

Liver regeneration after anatomical resections

BACKGROUND

The authors present the results of investigation of liver regeneration after partial parenchyma resection.

MATERIAL AND METHODS

20 patients (16 females, 4 male) aged 31-67 years were operated on because of metastatic colon cancer (7 cases), cavernous hemangioma (6 cases), hepatocellular carcinoma (1), alveococcosis (2), metastases of malignant melanoma (1), gall bladder carcinoma (1), FNH (1) and mucous cystadenocarcinoma (1). The resection according to anatomical segments by Couinaud were performed. Spiral CTs including liver volumetry were taken before and 30 days after the operation. on the 7-th day after the surgery, liver biopsy was performed and the material was examined under light and electron microscope.

RESULTS

There was no postoperative mortality. We observed transient elevation of transaminases, bilirubin levels and decrease of albumin level. Control spiral CT revealed increased liver volume in 15 cases (75 percent). In 16 cases (80 percent), electron microscopy investigations showed regeneration of the liver (mitotic figures).

CONCLUSIONS

Our material shows that hyperplasia as well as blood vessel and bile duct neogenesis play a very important role in liver regeneration process.

Risk factors for morbidity following liver surgery

The aim of this study is to define risk factors for severe complications following anatomical liver resections. The study material consists of the first 50 patients (26 women, 24 men, at mean age 50.6 years) treated at 3rd Department of Surgery 2nd Faculty of Medicine, Medical University in Warsaw. The indications for resection included benign neoplasm in 19 cases and malignancy in 31 cases. All the patients underwent anatomical liver resection in accordance with Couinaund's segmental division. In order to define prognostic factors for severe postoperative complications, a multi-factor statistical analysis was conducted. The following parameters were analysed: patient's age, the levels of bilirubin, total protein, albumin, prothrombin time, kaolin-kephalin time, range of resection and blood loss during operation. Eleven patients (22%) died in postoperative period. In 8 cases the death was caused by liver failure. Statistical analysis showed that blood loss, albumin level on fifth postoperative day and kaolin-kephalin time before and after surgery are independent risk factors predisposing to the development of complications.

Aldehyde dehydrogenase isoenzymes in tumours--assay with possible prognostic value for oxazaphosphorine chemotherapy

A novel fluorimetric assay, allowing independent measurement of the activities of two principal cytosolic forms of human aldehyde dehydrogenase, ALDH-1 and ALDH-3 (known as a tumour-associated ALDH) was applied to estimate the activities of these isoenzymes in human liver and thyroid tumours. The assay is based on two artificial substrates, 6-methoxy-2-naphthaldehyde (MONAL-62) and 7-methoxy-1-naphthaldehyde (MONAL-71), exhibiting excellent substrate properties toward various forms of human ALDH (see Wierzchowski et al., 1997, Anal. Biochem. 245, 69-78). We have found significant differences in ALDH activities between malignant and non-malignant tissue fragments, particularly in cancerous livers. Out of 16 tumours examined, only 4 exhibited ALDH-1 activities comparable to that found in the tumour-free tissue (0.5-2.5 U/g), while in the remaining 12 this activity was at least 10-fold lower. The ALDH-3 activity was detectable in about 40% of both tumour and tumour-free liver samples (maximum value 1.5 U/g). Comparison of 13 pathological thyroid fragments revealed ALDH activities in the range of 0.02 to 0.35 U/g, with two malignant samples showing activities of 0.27 and 0.18 U/g. Both substrate specificity and kinetic behaviour of the thyroid ALDH (Km values for the fluorogenic naphthaldehydes as well as propanal inhibition profile) were similar to those of the purified ALDH-1. In 5 thyroid samples traces of ALDH-3 activity was detected, using MONAL-62 and NADP+ as substrates (maximum value 0.04 U/g). Possible prognostic value of the foregoing measurements for cyclophosphamide chemotherapy is discussed.

Aldehyde dehydrogenase isoenzymes in tumours--assay with possible prognostic value for oxazaphosphorine chemotherapy

A novel fluorimetric assay, allowing independent measurement of the activities of two principal cytosolic forms of human aldehyde dehydrogenase, ALDH-1 and ALDH-3 (known as a tumour-associated ALDH) was applied to estimate the activities of these isoenzymes in human liver and thyroid tumours. The assay is based on two artificial substrates, 6-methoxy-2-naphthaldehyde (MONAL-62) and 7-methoxy-1-naphthaldehyde (MONAL-71), exhibiting excellent substrate properties toward various forms of human ALDH (see Wierzchowski et al., 1997, Anal. Biochem. 245, 69-78). We have found significant differences in ALDH activities between malignant and non-malignant tissue fragments, particularly in cancerous livers. Out of 16 tumours examined, only 4 exhibited ALDH-1 activities comparable to that found in the tumour-free tissue (0.5-2.5 U/g), while in the remaining 12 this activity was at least 10-fold lower. The ALDH-3 activity was detectable in about 40% of both tumour and tumour-free liver samples (maximum value 1.5 U/g). Comparison of 13 pathological thyroid fragments revealed ALDH activities in the range of 0.02 to 0.35 U/g, with two malignant samples showing activities of 0.27 and 0.18 U/g. Both substrate specificity and kinetic behaviour of the thyroid ALDH (Km values for the fluorogenic naphthaldehydes as well as propanal inhibition profile) were similar to those of the purified ALDH-1. In 5 thyroid samples traces of ALDH-3 activity was detected, using MONAL-62 and NADP+ as substrates (maximum value 0.04 U/g). Possible prognostic value of the foregoing measurements for cyclophosphamide chemotherapy is discussed.

Clostridium difficile in a department of surgery

The colonization and transmission of Clostridium difficile strains was investigated at the Department of Surgery. Anaerobes were isolated from fecal samples of 27 patients among 308 investigated (mean age: 59.5 years). The majority of them (22 out of 27 patients) received anti-microbial agents prior to investigation for Clostridium difficile. Eighteen of them had undergone various surgical procedures including laparotomies. Only four Clostridium difficile positive patients had diarrhea, but pseudomembranes were not observed endoscopically. The highest colonization rate of C. difficile (20/27) was found to occur in autumn. All 54 samples from medical personnel were C. difficile free. C. difficile was isolated in 7% of samples taken from hospital environment. Toxigenicity of Clostridium difficile strains isolated from fecal samples taken from patients and from environment was 78% and 80%, respectively, as determined by cytotoxicity tissue assay, or 70% and 20%, respectively, in the latex agglutination test.