The burden of neuropsychiatric disorders in patients living with HIV-1 treated with antiretroviral therapies-A perspective from US Medicaid data

BACKGROUND

People with human immunodeficiency virus (HIV)-1 face challenges with treatment adherence for various reasons, including consideration of neuropsychiatric disorders and neuropsychiatric adverse reactions associated with antiretroviral therapy (ART).

METHODS

A retrospective cohort study was conducted using administrative claims data from the IBM MarketScan^® Multi-State Medicaid Database (1/1/2014-12/31/2017). Adults (≥18 years) diagnosed with HIV-1 and newly initiated on antiretroviral therapy with continuous health plan enrollment were included. Primary outcome was the 6-month period prevalence of neuropsychiatric events (NPEs) of interest after ART initiation.

RESULTS

Among 1971 newly treated patients included in the study, mean age (standard deviation [SD]) was 38.5 (12.7) years, and 41.4% were female. During the 6 months after ART initiation, 51.4% of patients had a claim for ≥1 NPE versus 30.3% of matched patients without HIV. Among newly treated patients, the most common (≥10%) NPE claims were for depression (42.2%), anxiety (15.8%), headache (11.9%), and bipolar/manic depression (10.1%). Also in this group, the mean (SD) total all-cause healthcare cost during the 6-month post-ART initiation was $16,632 ($33,928), of which $2914 ($18,233) was NPE-related.

CONCLUSIONS

In summary, in this Medicaid study of people newly initiated on ART, there was a high prevalence of NPEs, and incremental NPE-associated costs were considerable.

Weight Gain and Related Comorbidities Following Antiretroviral Initiation in the 2000s: A Systematic Literature Review

Antiretroviral therapies (ARTs) benefit millions with human immunodeficiency virus. However, concerns about subsequent weight gain and related metabolic complications have emerged. Early ARTs are associated with adipose tissue changes. While newer ARTs may have fewer adipose alterations, it is unclear whether they lead to increased weight gain. A systematic literature review was performed to describe current published literature describing the use of newer ARTs, weight gain, and related comorbidities. Titles and abstracts were screened, focusing on studies that examined ART initiation and subsequent weight gain; publications were then ranked based on publication type, methodology, and comorbidities, emphasizing US studies with large patient cohorts. This yielded a comprehensive review of the 50 publications on weight gain and a range of related comorbidities, including diabetes and hypertension. Most of the studies describing weight gain found the most significant gains during the first year after initiating ART. Overall, patients gained ∼5 kg 18-96 months after initiating ART. Many of the studies reported altered weight-related comorbidities, including increased risk of diabetes and hypertension. Despite an expectation that newer ARTs may be safer, a review of the literature suggests that contemporary ART use is associated with pronounced weight gain and related comorbidities. Future studies should define and quantify the direct role of newer ARTs in weight gain and related comorbidities, as well as clarify the role of specific drug classes in metabolic disturbance, to improve intervention strategies.

Rapid initiation of darunavir/cobicistat/emtricitabine/tenofovir alafenamide in acute and early HIV-1 infection: a DIAMOND subgroup analysis

BACKGROUND

Treatment during acute or early human immunodeficiency virus (HIV)-1 infection is associated with immunologic and virologic benefits.

OBJECTIVE

To evaluate darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) efficacy/safety among patients with acute or early HIV-1 infection who rapidly initiate treatment.

METHODS

DIAMOND (ClinicalTrials.gov Identifier: NCT03227861), a phase 3 study, evaluated the efficacy/safety of D/C/F/TAF 800/150/200/10 mg in rapid initiation. Adults aged ≥18 years began D/C/F/TAF within 14 days of diagnosis, prior to the availability of screening/baseline laboratory results. In this subgroup analysis, virologic response (HIV-1 RNA <50 copies/mL) was assessed at Week 48 by intent-to-treat FDA snapshot (ITT-FDA snapshot) and observed (excluding patients with missing data) analyses in patients with acute (HIV-1 antibody negative and HIV-1 RNA positive/p24 positive) or early (HIV-1 antibody positive and suspected infection ≤6 months before screening/baseline) infection.

RESULTS

Among 109 patients, 13 had acute and 43 had early HIV-1 infection. High rates of virologic response were demonstrated at Week 48 by ITT-FDA snapshot (acute: 10/13 [76.9%]; early: 37/43 [86.0%]) and observed (acute: 10/11 [90.9%]; early: 37/38 [97.4%]) analyses. No patients discontinued or required regimen change due to baseline resistance or lack of efficacy, or developed protocol-defined virologic failure. Through Week 48, 7 (53.8%) acute and 22 (51.2%) early infection patients had a D/C/F/TAF-related adverse event (AE); none had a D/C/F/TAF-related grade 4 or serious AE.

CONCLUSIONS

High rates of viral suppression during acute/early infection were achieved with D/C/F/TAF rapid initiation, no treatment-emergent resistant mutations were observed, and D/C/F/TAF was safe and well tolerated.

Antiretroviral Adherence, Drug Resistance, and the Impact of Social Determinants of Health in HIV-1 Patients in the US

Adherence to antiretroviral therapy (ART) is critical to achieving viral suppression. However, social determinants of health (SDoH) can undermine patient adherence to ART, resulting in drug resistance that compromises future treatment options. We assessed ART adherence and HIV-1 drug resistance at the national and state levels in the US and investigated their associations with SDoH and other HIV-related outcomes. Data were obtained from Symphony Health's Integrated Dataverse (IDV), Monogram/LabCorp Database, as well as national and publicly available databases, including Centers for Disease Control and Prevention (CDC), American Community Survey (ACS), and J. Kaiser Family Foundation (KFF). Inferential analyses were performed to investigate associations using patient-level data, and the results were reported by state and overall within the nation. Correlations between continuous variables were estimated by the Spearman's test, and that between continuous variable and categorical variable were estimated using one-way analysis of variance (ANOVA). State-level rates of poor adherence and resistance ranged from 26 to 55% and 20 to 54%, respectively. Female gender, non-white race, low education, poverty, and unemployment were associated with poor adherence; female gender was associated with drug resistance. Both adherence and resistance were correlated to HIV prevalence rates. Our findings suggest that US patients living with HIV face great challenges associated with poor ART adherence and HIV-1 drug resistance.

An assessment of weight change associated with the initiation of a protease or integrase strand transfer inhibitor in patients with human immunodeficiency virus

OBJECTIVE

Evidence suggests that integrase strand transfer inhibitors (INSTIs) are associated with greater weight gain than other antiretrovirals. This real-world study compares weight/body mass index (BMI) change between insured US patients with human immunodeficiency virus (HIV-1) initiating a protease inhibitor (PI) or INSTI.

METHODS

A retrospective longitudinal study was conducted using Decision Resources Group's Real World Data Repository (7/17/2017-6/1/2019). Adult patients with HIV-1 who initiated a new PI or INSTI on or after 7/17/2018 (index date) and had ≥12 months of continuous pre-index clinical activity were included. Baseline characteristics were balanced using inverse probability of treatment weighting. The proportion of patients with ≥5% weight/BMI increases and mean weight/BMI change from pre- to post-index were compared using odds ratios (ORs) and mean differences (MDs).

RESULTS

20,367 patients (9993 PI, 10,374 INSTI) were included (mean age = 50 years; ∼30% females). Pre- and post-index weight and BMI measurements were available in 429 and 430 PI patients, and 397 and 383 INSTI patients, respectively (mean time between index and post-index measurements: ∼7 months). The PI cohort was 39%/49% less likely to experience ≥5% weight/BMI increase than the INSTI cohort, respectively (OR [≥5% weight gain] = 0.61; p = .014; OR [≥5% BMI gain] = 0.51; p < .001). Mean weight/BMI gain was significantly lower in the PI cohort than the INSTI cohort (weight MD = -1.90 kg [-4.19 lbs], BMI MD = -0.61kg/m²; both p < .001).

CONCLUSIONS

Relative to INSTI, patients initiating a new PI were less likely to experience ≥5% weight/BMI gain post-index. Additionally, mean weight/BMI gain was lower in the PI than in the INSTI cohort.

Treatment Patterns and Predictors of Adherence in HIV Patients Receiving Single- or Multiple-Tablet Darunavir, Cobicistat, Emtricitabine, and Tenofovir Alafenamide

PURPOSE

Darunavir, cobicistat, emtricitabine, and tenofovir alafenamide can be used as a single-tablet regimen (STR, DRV/c/FTC/TAF) or multiple-tablet regimen (MTR, DRV/c+FTC/TAF) to treat patients with human immunodeficiency virus (HIV). This study described treatment patterns and predictors of adherence among patients with HIV initiated on DRV/c/FTC/TAF or DRV/c+FTC/TAF.

PATIENTS AND METHODS

A retrospective longitudinal study was conducted using linked claims and electronic medical records from Decision Resources Group's Real World Data Repository (7/17/2017-6/1/2019). Treatment-naïve and treatment-experienced virologically suppressed adults with HIV-1 prescribed DRV/c/FTC/TAF or DRV/c+FTC/TAF (index date) were included. Six-month persistence (no treatment gaps >60 and >90 days) and adherence (proportion of days covered [PDC]) to the index regimen were evaluated among patients with ≥6 months of observation post-index. Predictors of low adherence (PDC<80%) were evaluated using a logistic regression model.

RESULTS

Among 2633 eligible patients (49.5 years old, 29% female, 37% African American/Black), 12% were treatment-naïve pre-index and 88% switched from a previous antiretroviral therapy; 84% initiated DRV/c/FTC/TAF and 16% initiated DRV/c+FTC/TAF. Among 822 DRV/c/FTC/TAF patients with ≥6 months of observation post-index, 80% and 86% had no >60- and >90-day gaps in DRV/c/FTC/TAF coverage, respectively, while among 204 DRV/c+FTC/TAF patients with ≥6 months of observation post-index, 69% and 75% had no >60- and >90-day gaps in DRV/c+FTC/TAF coverage, respectively. Mean (median) PDC for the index regimen was 81% (93%) for patients treated with DRV/c/FTC/TAF and 73% (83%) for patients treated with DRV/c+FTC/TAF. Predictors of low adherence included younger age (odds ratio [OR]=2.36, p=0.017), higher Quan-Charlson comorbidity index (OR=1.32, p=0.012), use of MTR regimen at index (OR=1.69, p=0.022), and prior low adherence (OR=2.56, p<0.001).

CONCLUSION

Among patients initiating a DRV/c-based regimen, those initiating STR had higher 6-month adherence/persistence than those initiating MTR, highlighting the potential benefits of the STR formulation, particularly among younger patients with multiple comorbidities and prior low adherence.

Adherence to Antiretroviral Therapy: The Emerging Role of HIV Pharmacotherapy Specialists

Despite the availability of 25 antiretroviral agents to treat HIV infection and the significant progresses made in the clinical pharmacology of HIV drugs, viral suppression and immune restoration remain problematic in a large number of HIV-infected persons. One of the main factors responsible for this partial therapeutic success is the difficulty patients have adhering consistently to antiretroviral therapy. Barriers to adherence are diverse and complex and evolve over time, complicating the monitoring of medication-taking behaviors. Consequently, multilevel interventions are often needed to address thoroughly adherence issues. Given the rapid and constant evolution of HIV treatments, innovative multidisciplinary programs integrating HIV pharmacotherapy specialists, as the “medication expert,” are being implemented. Because of his or her advanced knowledge of antiretrovirals, the HIV pharmacotherapy specialist is highly qualified to evaluate patients with complex regimens who are facing barriers to successful care and who need tailored interventions and long-term follow-up.

[Current Nomina Anatomica for oral and maxillofacial surgery]

Using the international organonymy is mandatory as well for daily clinical practice as for research and teaching our students. The international organonymy, Nomina Anatomica, is in Latin. A rather unsuccessful attempt at using a French version of the international organonymy in clinical practice has been made in France. Eponyms have been systematically contraindicated; the definitions of general anatomy are applied, as well as a systematic Gallicization of the Latin terminology. Despite a stringent observance of these rules, some terms remain inappropriate because they are misleading or inaccurate. Furthermore, using this language used worldwide remains uneasy in daily clinical practice. We had for objective to focus on the main anatomical terms used routinely in oral and maxillofacial surgery, and to justify their use in clinical practice, research, and education.

[Can one harvest a long bone stick in the radial forearm flap? Original radioanatomical and NanoSPECT-CT Bioscan microvascular study]

OBJECTIVES

The composite radial forearm flap is a surgical option in the reconstruction of large traumatic or oncologic orofacial defects. Nevertheless, it has been criticized for its poor bone transport faculties that would make this flap insufficient in large osseous mandibular reconstructions, or for oral prosthetic rehabilitation with dental implants. What is more, the morbidity of the donor site has often been pointed. The aim of this radioanatomic study was to revisit the vascularization of the composite radial forearm flap, focusing on the bone stick.

METHODS

A radioanatomic study was performed on seven upper limbs taken from fresh cadavers. First, the vessels were washed with a 40°C solution of potassium acetate. Then an intra-arterial injection of a mixture of lead oxide and agar-agar was performed. 3D-CT-scan examinations of the anatomical pieces were performed. In a second step, the flaps were harvested and analyzed with a Microscan examination (NanoSPECT-CT Bioscan(®), voxel 220 microns). Collateral branches of the radial artery to the bone and the skin were counted and classified.

RESULTS

One radial diaphyseal artery was present in all the cases. The nutrient foramen took place at the anteromedial aspect of the diaphysis, between 45 and 65 % of the length of the bone. A dense anastomotic periosteal network was highlightened, supplied by one to four musculoperiosteal branches, and one to six fascio-periosteal arteries arising from the radial artery. A total of mean five osseous branches, and 12 cutaneous branches have been observed.

CONCLUSIONS

The results of the present preclinical study suggested that a 16-cm bone stick could be harvested with an optimal vascular safety, without consideration for the morbidity at the donor site. The original approach in this study, relating anatomy to the preclinical imaging, allowed a precise visualization of the microvascularization of the soft and hard tissues. It opened a field of innovative research in plastic and reconstructive surgery.

Clinical and pharmacogenetic factors affecting neonatal bilirubinemia following atazanavir treatment of mothers during pregnancy

A theoretical concern exists that atazanavir (ATV) use during pregnancy may exacerbate physiologic neonatal hyperbilirubinemia. The aim of this substudy was to evaluate patterns of neonatal bilirubin following ATV/ritonavir (RTV) treatment of pregnant mothers and clinical and pharmacogenetic factors that may correlate. The design involved a subanalysis of study AI424182, a multicenter, open-label, prospective, single-arm Phase I study. The study had two treatment arms: (1) ATV/RTV 300/100 mg once daily or (2) ATV/RTV 400/100 mg once daily, both in combination with zidovudine/lamivudine 300/150 mg twice daily. Total bilirubin was assessed at baseline, each visit, and delivery day for mothers and on days 1 (delivery day), 3, 5, and 7 and weeks 2 and 6 for neonates. Blood samples were obtained for UGT1A1 genotyping and ATV cord blood concentration. Bilirubin elevation of any grade occurred in 14/40 neonates (35%). All Grade 3 to 4 bilirubin abnormalities (n=7) occurred after day 14. The pattern of neonatal bilirubin levels reported was consistent with neonatal physiologic elevations of bilirubin. Little correlation was observed between either maternal bilirubin levels over the last 4 weeks of pregnancy (including delivery) or ATV cord concentration and neonatal bilirubin. There was a significant association between UGT1A1 genotype and bilirubin grade in the maternal population (p=0.0006) but not neonates (p=0.49). Neither neonatal UGT1A1 genotype nor cord blood ATV concentration is a good predictor of neonatal hyperbilirubinemia. ATV/RTV treatment of mothers does not appear to exacerbate neonatal physiologic hyperbilirubinemia.

Atazanavir pharmacokinetics, efficacy and safety in pregnancy: a systematic review

BACKGROUND

For some antiretroviral therapies, drug concentrations are reduced during pregnancy, potentially compromising effective virological suppression.

METHODS

Data on atazanavir boosted with ritonavir in pregnancy are reviewed.

RESULTS

With standard atazanavir/ritonavir 300/100 mg once-daily dosing: atazanavir area-under-the-concentration-time curves were reduced during pregnancy in most studies, but overall interpretation differed according to the data used for comparison; atazanavir concentration 24 h post-dose was maintained >150 ng/ml in 97.6% of women; no instance of mother-to-child transmission occurred in treatment-adherent mothers; and infant hyperbilirubinaemia was not elevated beyond levels expected in the neonatal period.

CONCLUSIONS

With concurrent medications that reduce atazanavir drug concentrations, optimal therapy during pregnancy may require once-daily atazanavir/ritonavir 400/100 mg; however, using this dose during the third trimester doubled maternal grade 3-4 hyperbilirubinaemia rates.

Simultaneous demonstration of horseradish peroxidase and acetylcholinesterase

Simultaneous demonstration of acetylcholinesterase (AChE) and horseradish peroxidase (HRP) has been achieved by staining frozen sections with a modified Koelle-Friedenwald thiocholine method for AChE followed directly by the Graham-Karnovsky procedure for HRP. By using sodium sulfite instead of sodium sulfide in the AChE procedure, the final reaction product appears as black AChE granules that contrast sharply with the yellowish-brown HRP granules.

Development and field testing of an HIV medication touch screen computer patient adherence tool with telephone-based, targeted adherence counseling

BACKGROUND

HIV medication nonadherence is a major problem, yet many providers lack the time and training to carefully ask patients about their adherence.

OBJECTIVE

To design and pilot a technology-assisted intervention, for use in clinical settings, to identify nonadherent patients.

METHODS

The intervention uses audio computer-assisted self-interview (ACASI) to improve the assessment of adherence and medication-related problems. Patients completed a touch screen computer ACASI which generated graphic clinician and patient reports for discussion during the clinical encounter.

RESULTS

72 patients and 11 providers participated in this study. The patients easily completed the ACASI. Adherence was 63% (3-day) and 47% (30-day). Using the ACASI, 22% of patients identified themselves as nonadherent, when their providers perceived them as adherent.

CONCLUSIONS

This ACASI-based intervention is easy to use and helps identify nonadherence. The pilot test engendered enhancements including the addition of phone-based adherence counseling. A larger trial is underway to evaluate whether the intervention leads to improved HIV-related outcomes.

[An update on focal infection of oral origin]

Focal infection of oral origin means that an oral infectious focus may have widespread effects. This concept remains controversial since it is difficult to prove the oral origin of germs responsible for an extra-oral infection. Experiments on animal models and clinical studies suggested several physiopathological mechanisms: bacteremia, toxinic and immunological mechanisms. Various operations induce the passage of bacterial flora (transcytosis) and its toxins into the bloodstream: oral care, chewing, or tooth brushing. Bacteremia is worsened by poor oral hygiene or an infection. The germs are usually destroyed by the host's reticuloendothelial system in a few minutes, but the presence of a valvular disease or a weak immune system favors focal infection. Besides infectious endocarditis, this may concern cardiovascular diseases, lung infections, prematurity and hypotrophy, diabetes, prosthetic infections, cerebral abscesses, etc. This update is based on literature review, selected according to its high level of scientific proof, as well as on a selected choice of consensus conferences. The current recommendation is to limit antibiotic prophylaxis to the high bacteremia risk procedures and to patients highly at risk of developing a focal infection.

[Mixed odontogenic tumours]

Mixed odontogenic tumors include all tumors of the teeth both epithelial and mesenchymatous. Most of these tumors are rare (ameloblastic fibroma, ameloblastic fibro-odontoma and fibrodentinoma, odontoameloblastoma, calcified odontogenic cyst). Other tumors such as odontoma are frequent. They have in common a benign aspect, their often-fortuitous observation, a higher rate in the young adult and surgical treatment by complete exeresis preventing recurrence. They present a radiolucent lacuna but appear different depending on the presence or not of intralesional calcifications revealing the production of more or less mature dental tissue. The diagnosis may be confirmed only by an anatomopathological examination, along with clinical and radiological observations.

Enfuvirtide, a New Fusion Inhibitor for Therapy of Human Immunodeficiency Virus Infection

Enfuvirtide is the first fusion inhibitor to be approved by the Food and Drug Administration for the treatment of chronic human immunodeficiency virus (HIV) infection in adults and children 6 years and older. The drug is a synthetic peptide derived from a naturally occurring amino acid sequence known as heptad repeat 2 (HR2) found in gp41, a viral transmembrane glycoprotein that facilitates fusion with host cells. By mimicking the activity of HR2 and competitively binding to a second region of gp41, heptad repeat 1 (HR1), enfuvirtide prevents interaction between HR1 and HR2 and inhibits the conformational change of gp41 that is necessary for fusion of virions to host cells. The safety and efficacy of enfuvirtide have been studied only in antiretroviral-experienced persons. Preliminary data from two multicenter phase III clinical trials (T-20 versus Optimized Regimen Only [TORO 1, TORO 2]) suggest that the drug is safe and efficacious in heavily pretreated subjects through 24 weeks. By week 24, in TORO 1 and TORO 2, respectively, mean changes in HIV RNA concentrations of -1.7 and -1.4 log10 copies/ml were observed in subjects receiving enfuvirtide plus an optimized background (OB) regimen, compared with changes of -0.8 and -0.7 log10 copies/ml in subjects receiving an OB regimen alone. Resistance to enfuvirtide has been identified in vitro and in vivo. Most resistant variants contain mutations in the HR1 region of gp41 (positions 36-45). In phase III clinical trials, numerous substitutions within this critical region were associated with faster time to virologic failure over 24 weeks. Overall, enfuvirtide appears to be well tolerated and acceptable to patients despite a high rate of injection site reactions (> 90%). Bacterial pneumonia and eosinophilia occurred more frequently in subjects taking enfuvirtide than in those taking an OB regimen alone in phase III trials; however, no causal relationship was established. Like most drugs with peptide structures, enfuvirtide appears to have a low potential for metabolic drug-drug interactions. The approved dosage is 90 mg twice/day by subcutaneous injection in adults and 2 mg/kg twice/day in children older than 6 years. Enfuvirtide is an addition to antiretroviral therapy since it targets a new step in the HIV life cycle. Given the complexity of its production and administration, however, it is likely to be most useful in antiretroviral-experienced patients.

Web database of molecular genetic data from fish stocks

Much research at the national and international level has been devoted to the development of several genetic methods for use in the characterization of fish stocks. We have developed a database that collates data from population genetic studies of fish. This database is accessible to researchers and control authorities on the Internet and should serve as a repository for genetic information of commercially important fish species. The prototype database has been developed in such a way that the new information can easily be updated by researchers in the field, who can submit their own data. The site can be found at http://fishgen.jrc.it.

Bactericidal effect of a whey protein concentrate with anti-Helicobacter pylori activity

AIMS

To investigate the effect of whey protein concentrate (WPC) enriched in anti-Helicobacter pylori antibodies on growth of the organism in vitro.

METHODS AND RESULTS

A WPC rich in H. pylori-specific antibodies was produced by immunizing lactating cows against H. pylori and processing pooled bulk milk samples into whey powder. The antibodies bound several proteins within the bacterial homogenate and were active at pH 5. In a complement-dependent reaction, the immune WPC was highly bactericidal against four H. pylori strains tested in vitro.

CONCLUSION

WPC produced with milk from H. pylori-immunized cows contains antibodies that are active at the pH of the stomach, and bactericidal against H. pylori in vitro, via the classical complement pathway.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study has demonstrated the potential for use of WPC in the prevention/treatment of H. pylori infections.

Glucose disorders associated with HIV and its drug therapy

OBJECTIVE

To review the impact that factors such as HIV infection, antiretrovirals, and other commonly used drug therapies have on glucose metabolism in HIV-infected patients.

DATA SOURCES

Pertinent literature was identified via a MEDLINE search from 1980 to April 2000 and through secondary sources (abstracts presented at recent scientific meetings, manufacturers' package inserts). The key words used were antiretroviral therapy, HIV infection, insulin resistance, and metabolic abnormalities. All information deemed relevant to evaluate the impact that HIV infection and drug therapy have on glucose metabolism in HIV-infected patients was included.

DATA SYNTHESIS

The viral burden and stress that are present in HIV-infected patients elicit a complex hormonal and immunologic response that may alter various biochemical pathways, including glucose metabolism. Although rare before the era of potent antiretroviral therapy, insulin resistance has now been described as an important component of the lipodystrophy syndrome. The complex and multifactorial nature of glucose metabolism dysregulation makes management of hyperglycemia or diabetes mellitus challenging in HIV-infected patients. In such a context, a set of recommendations was developed to guide practitioners in assessing, treating, and monitoring hyperglycemia or diabetes mellitus in HIV-infected patients.

CONCLUSIONS

Alterations of glucose metabolism observed in HIV-infected patients are more frequent since the introduction of potent antiretroviral therapy. Although the etiology of such abnormalities remains unknown, protease inhibitors and, to a lesser extent, nucleoside reverse transcriptase inhibitors are believed to participate in their pathogenic mechanisms. Because of similarities to the pathogenesis of diabetes mellitus, management of antiretroviral-induced hyperglycemia could follow that the recommendations of the American Diabetes Association, with special considerations for monitoring patients with HIV infection. Future studies of altered glucose metabolism in HIV-infected patients should focus on understanding the precise mechanism or causes of this complication so that preventive and therapeutic guidelines can be further evaluated.

Lack of acute cyclosporine nephrotoxicity in late heart-transplant recipients

BACKGROUND

Cyclosporine induces daily renal hypoperfusion in subjects with normal atrial natriuretic peptide (ANP) levels, but its acute effects in heart transplant patients with increased ANP remain to be determined.

METHODS

Cyclosporinemia and creatinine clearance were monitored during 7 hours following cyclosporine administration in 6 heart transplant patients.

RESULTS

CONCLUSIONS

No acute cyclosporine-induced decrease in creatinine clearance was observed after heart transplantation. These data suggest that maintenance cyclosporine dose may be less nephrotoxic than suspected and that increased ANP might protect the renal function late after heart transplantation.

Enhanced natriuretic response to neutral endopeptidase inhibition in heart-transplant recipients

Heart-transplant recipients (Htx) generally present with body fluid and sodium handling abnormalities and hypertension. To investigate whether neutral endopeptidase inhibition (NEP-I) increases endogenous atrial natriuretic peptide (ANP) and enhances natriuresis and diuresis after heart transplantation, ecadotril was given orally to 8 control subjects and 8 matched Htx, and levels of volume-regulating hormones and renal water, electrolyte, and cyclic guanosine monophosphate (cGMP) excretions were monitored for 210 minutes. Baseline plasma ANP, brain natriuretic peptide (BNP), and cGMP were elevated in Htx, but renin and aldosterone, like urinary parameters, did not differ between groups. NEP-I increased plasma ANP (Htx, 20.6+/-2.3 to 33.2+/-5.9 pmol/L, P<0.01; controls, 7.7+/-1. 2 to 10.6+/-2.6 pmol/L) and cGMP, but not BNP. Renin decreased similarly in both groups, whereas aldosterone decreased significantly only in Htx. Enhanced urinary sodium (1650+/-370% versus 450+/-150%, P=0.01), cGMP, and water excretions were observed in Htx and urinary cGMP positively correlated with natriuresis in 6 of the Htx subjects. Consistent with a normal circadian rhythm of blood pressure, without excluding a possible effect of NEP-I, mean systemic blood pressure increased similarly in both groups at the end of the study (6.9+/-2.0% versus 7.4+/-2.8% in controls and Htx). Thus, systemic hypertension, mild renal impairment, and raised plasma ANP levels are possible contributory factors in the enhanced natriuresis and diuresis with NEP-I in Htx. These results support a physiological role for the cardiac hormone after heart transplantation and suggest that long-term studies may be useful to determine the potential of NEP-I in the treatment of sodium retention and water retention after heart transplantation.

The afferent connections of the main and the accessory olfactory bulb formations in the rat: an experimental HRP-study

The afferent connections of the main and accessory olfactory bulbs in the rat were examined by injecting horseradish peroxidase (HRP) into one or the other of these structures either by microelectrophoresis or by hydraulic pressure. Alternate sections were stained with newly developed HRP-procedures using either benzidine dihydrochloride (de Olmos and Heimer, '77) or tetramethyl-benzidine. Eighteen to twenty-four hours after unilateral HRP injections confined to the main olfactory bulb, a large number of HRP-labeled perikaria appeared in the following telencephalic structures on the ipsilateral side: All portions of the anterior olfactory nucleus (AON) except its external part, the lateral transitional field (LT) between AON and the paleocortex, the whole extent of the primary olfactory cortex (POC); the medial forebrain bundle area deep to the olfactory tubercle, the nucleus of the horizontal limb of the diagonal band (NHDB) and the nucleus of the lateral olfactory tract (NLOT). A moderate to small number of labeled cells, furthermore, were seen in the dorsal (DT) and medial (MT) transition fields, the ventral praecommissural hippocampus (tt2), the ventral superficial part of the nucleus of the vertical limb of the diagonal band (NVDB), the sublenticular part of the substantia innominata (SI), the anterior amygdaloid area, the posterolateral cortical amygdaloid nucleus (C2) and the transition region (28 L') between the olfactory cortex and the lateral entorhinal area proper. On the contralateral side a large number of labeled cells were found in all parts of the AON, with especially heavy labeling in its external part. A moderate number of labeled cells could also be detected in the lateral transition field (LT) and the NLOT. In the diencephalon and the brain stem a moderate number of HRP-labeled perikaria were observed in the dorsal, perifornical, and lateral hypothalamus, as well as in locus coeruleus and the dorsal and medial raphae nuclei. Following large HRP injections in the main olfactory bulb a moderate to small number of labeled cells were seen also in the posterior and premammillary hypothalamus and in field CA1 of the retrocommissural hippocampus on the ipsilateral side, as well as in POC on the contralateral side. It is possible, however, that the uptake of label took place in an undetected pool of HRP in the very rostal part of AON rather than in the olfactory bulb. HRP injections in the accessory olfactory bulb resulted in labeled neurons in the posterior ventro-lateral part of the bed nucleus of the stria terminalis, the nucleus of the accessory olfactory tract, the rostrodorsal portions of the medial amygdaloid nucleus, and the whole extent of the posteromedial cortical amygdaloid nucleus (C3) on the ipsilateral side. A few lightly labeled cells were seen also in the contralateral C3.