Mild SARS-CoV-2 infection in vulnerable patients: implementation of a clinical pathway for early treatment

INTRODUCTION

The objective of this report is to describe the clinical pathway for early treatment of patients with acute SARS-CoV-2 infection and to evaluate the first results of its implementation.

METHODS

This is a descriptive and retrospective study of the implementation of a clinical pathway of treatment in outpatients (January 1 to June 30 2022). Clinical pathway: detection and referral systems from Primary Care, Emergency services, hospital specialities and an automated detection system; clinical evaluation and treatment administration in the COVID-19 day-hospital and subsequent clinical follow-up. Explanatory variables: demographics, comorbidity, vaccination status, referral pathways and treatment administration.

OUTCOME VARIABLES

hospitalization and death with 30 days, grade 2-3 toxicity related to treatment.

RESULTS

Treatment was administered to 262 patients (53,4% women, median age 60 years). The treatment indication criteria were immunosupression (68,3%), and the combination of age, vaccination status and comorbidity in the rest 47,3% of the patients s received remdesivir, 35,9% nirmatrelvir/ritonavir, 13,4% sotrovimab and 2,4% combined treatment with a median of 4 days after symptom onset. Hospital admission was required for 6,1% of the patients, 3,8% related to progression COVID-19. No patient died. Toxicity grade 2-3 toxicity was reported in 18,7%, 89,8% dysgeusia and metallic tasted related nirmatrelvir/ritonavir. Seven patients discontinued treatment due to toxicity.

CONCLUSION

The creation and implementation of a clinical pathway for non-hospitalized patients with SARS-CoV-2 infection is effective and it allows early accessibility and equity of currently available treatments.

[Mild SARS-CoV-2 infection in vulnerable patients: implementation of a clinical pathway for early treatment]

INTRODUCTION

The objective of this report is to describe the clinical pathway for early treatment of patients with acute SARS-CoV-2 infection and to evaluate the first results of its implementation.

METHODS

This is a descriptive and retrospective study of the implementation of a clinical pathway of treatment in outpatients (January 1 to June 30 2022). Clinical pathway: detection and referral systems from Primary Care, Emergency services, hospital specialities and an automated detection system; clinical evaluation and treatment administration in the COVID-19 day-hospital and subsequent clinical follow-up. Explanatory variables: demographics, comorbidity, vaccination status, referral pathways and treatment administration.

OUTCOME VARIABLES

hospitalization and death with 30 days, grade 2-3 toxicity related to treatment.

RESULTS

Treatment was administered to 262 patients (53,4% women, median age 60 years). The treatment indication criteria were immunosupression (68,3%), and the combination of age, vaccination status and comorbidity in the rest47,3% of the patients s received remdesivir, 35,9% nirmatrelvir/ritonavir, 13,4% sotrovimab and 2,4% combined treatment with a median of 4 days after symptom onset. Hospital admission was required for 6,1% of the patients, 3,8% related to progression COVID-19. No patient died. Toxicity grade 2-3 toxicity was reported in 18,7%, 89,8% dysgeusia and metallic tasted related nirmatrelvir/ritonavir. Seven patients discontinued treatment due to toxicity.

CONCLUSION

The creation and implementation of a clinical pathway for non-hospitalized patients with SARS-CoV-2 infection is effective and it allows early accessibility and equity of currently available treatments.

[COVID-19 associated mucormycosis. A case in Argentina]

SARS-CoV-2 virus disease presents variable severity. Recently, an increasing report of cases of COVID-19 associated mucormycosis (CAM) has been observed, mainly in patients with diabetes mellitus, diabetic ketoacidosis or under steroids treatment. The highest number of cases have been reported in India, with a prevalence of 0.27 % in hospitalized patients with COVID-19 during year 2020, which implies a 2.1-fold increase in the prevalence of mucormycosis compared to year 2019. Although corticosteroids treatment reduces mortality in patients with severe COVID-19, its prolonged use, in combination with other clinical and immunological factors, could increase the risk of invasive fungal infection. We report a case of CAM in Argentina. This report represents a warning for considering the diagnosis of invasive fungal infection in patients with severe COVID-19.

Presenting stage and risk group in men dying of prostate cancer

Introduction

Prostate cancer remains the 3rd leading cause of cancer-related mortality in Canadian men, and yet screening for prostate cancer continues to be controversial because the majority of men diagnosed with prostate cancer do not die of the disease. It also remains uncertain whether treatment of cases that can be treated with curative intent alters the mortality rate. There are very few studies describing the presenting stage, risk groups, and survival after diagnosis for men dying of prostate cancer in the literature. In this study, we explored these characteristics for all men who died of prostate cancer in British Columbia between 2013 and 2015.

Methods

The population-based BC Cancer databases were used to identify all patients diagnosed between January 2013 and December 2015 who died of prostate cancer. Patient, tumour, and treatment characteristics were collected, and the risk grouping for each tumour was determined. The proportion of cases in each risk group at the time of diagnosis was determined. Survival time from diagnosis to death was calculated for all patients and for each risk group using the Kaplan-Meier method.

Results

A total of 1256 patients died of prostate cancer. Of patients who presented with metastatic disease, 57.2% presented with a Gleason score of 8 or more, compared with only 35.7% of patients who presented with nonmetastatic disease (p < 0.0001). The presenting stage and risk group of those dying of prostate cancer were as follows: 32% metastatic disease, 3% regional (defined as node-positive), 39% localized high risk, 9% localized intermediate risk, 4% localized low risk, 6% localized not otherwise specified, and 7% unknown. Therefore, 80.3% of those with a known risk group presented with either localized high-risk, regional, or metastatic disease at diagnosis. The median survival times from diagnosis to death were 12 years for localized low-risk, 10 years for localized intermediate-risk, 6.5 years for localized high-risk, 4 years for regional, and 1.7 years for metastatic disease at diagnosis.

Conclusions

This population-based analysis demonstrates that patients with localized high-risk, regional, or metastatic disease at diagnosis constitute the overwhelming majority of patients who die of prostate cancer in British Columbia. Unless these disease states can reliably be identified at an earlier low- or intermediate-risk localized state in the future, it is unlikely that treatment of localized low- and intermediate-risk cancer will have an impact on survival. Furthermore, patients with de novo metastatic disease had identifiable risk factors of a higher prostate-specific antigen and Gleason score. Further studies are required to confirm these results.

SUN-494 A Case of Hyperthyroidism with Multiple Recurrences of Neutropenia After Stopping Methimazole

Background: The adverse effects of methimazole usually occur in the first 6 months of treatment and they usually are dose dependent. The most severe ones are hepatotoxicity and agranulocytosis, the frequency of the latter is 0.1-0.5% and with a high mortality rate.

Clinical case: A 15-year-old female patient was sent to Endocrinology in May 2017 because of a 4-month history of tremor, palpitations and heat intolerance. Lab tests: WBC: 6,800, neutrophils: 36% (2,448/l), TSH: < 0.06 uU/ml (0.27- 4.7), T4: > 25 ug/dl (4.5 -12), FT4: >7.7 ng/dl (0.93 -1.7), TPO >1,000 UI/ml (<10), TRAb > 40 UI/L (<1.75) which confirmed Graves’ disease. Propranolol 80 mg/day and methimazole 30 mg/day were prescribed. Two months later methimazole dose was increased to 40 mg/d, hematologic lab test was normal. Seven months after starting methimazole the patient presented with febrile neutropenia, methimazole was stopped, methylprednisolone 20 mg/d was prescribed and we increased propranolol to 120 mg/d, neutropenia improved. A month after the first episode of neutropenia, she presented a second episode with a pharyngeal infection, WBC: 6,300, neutrophils: 1%. In December 2017 radioiodine therapy was performed: 15 mCi. Hyperthyroidism was not resolved, she continued with methylprednisolone 20 mg/d and propranolol 120 mg/d, and 6 drops/d of Lugol solution was prescribed. From December 2017 to July 2018, the patient presented 9 episodes of febrile neutropenia, she had a good response to Granulocyte-colony stimulating factor. Serology tests for CMV, VDRL, HIV, Epstein Barr, Toxoplasmosis, hepatitis B and C were all negative. Lab tests for rheumatologic diseases: rheumatoid factor, C3 and C4, electrophoretic proteinogram, antiestreptolysin O, anti-DNA, ANA, anti-Ro/SSA, anti-La/SSB were all negative, and immunoglobulins were normal. Bone marrow aspiration was normal. We could not perform flow cytometry of anti-neutrophil cytoplasmic antibodies (C-ANCA). Hyperthyroidism persisted and a second I-131 treatment was performed (20 mCi) in June 2018. A month later she presented hypothyroidism, levothyroxine was indicated. She continued with episodes of febrile neutropenia until March 2019, 23 months after the diagnosis of hyperthyroidism, 16 months after stopping methimazole and 8 months after having initiated levothyroxine treatment and having normal thyroid levels.

Conclusion: We presented a young female patient with persistent and recurrent neutropenia despite having stopped methimazole, and regardless of her thyroid hormone levels. Although neutropenia usually appears in the first months of treatment, it seldom occurs much later and almost never after stopping the drug. We could not reach an etiological diagnosis of neutropenia, but it is probable that methimazole had triggered an immune-hematological illness associated to Graves’ disease.

Abstract P1-16-05: Prognosis and survival in metastatic breast cancer – Ten years in review, a population-based analysis

Background: The rapidly evolving landscape of systemic treatment for metastatic breast cancer (MBC) during the 1990s led to meaningful improvements in the overall survival (OS) of MBC patients[1]. Despite ongoing and expanded access to new treatments, it remains unclear if this has translated into further advances in survival. Moreover, the prognosis of MBC patients based on subtype, over time, are also important to differentiate.

Methods: The BC Cancer Breast Cancer Outcomes Unit (BCOU) database was utilized to identify patients referred to BC Cancer who were diagnosed with MBC during 3 time cohorts (cohort 1:2003-2005; cohort 2:2007-2009; cohort 3:2011-2013), to reflect changes in MBC treatment over these separate time periods. Baseline clinical and pathological criteria were compiled, in addition to adjuvant treatments received, as well as number of lines of treatment in the metastatic setting. OS was compared across time cohorts for all patients and then between subtypes using Kaplan-Meier survival curves.

Results: A total of 3,953 patients met the inclusion criteria, consisting of 2,440 (61.7%) estrogen-receptor positive (ER+), 778 (19.7%) HER2 positive and 542 (13.7%) triple-negative breast cancer (TNBC) patients. One hundred and ninety-three patients (4.9%) were unable to be subtyped and were therefore excluded from the analysis . A total of 2,205 (90.4%) ER+ patients received at least 1 line of systemic therapy, with 80.0% receiving at least 1 line of hormonal therapy. The median time on hormonal treatment was 8.9 months (range 0.03 - 156.7) for first-line and 6.1 months (range 0.1 – 173.3) for second-line. In the HER2+ group, 665 (85.5%) patients received at least 1 line of treatment, with a median of 2 lines of treatment (range 1-16). Median duration of anti-HER2 treatment was 6.7 months (range 0.03 - 163.8) with a median of 1 line of anti-HER2 directed treatment (range 1-5). For TNBC patients, 357 (65.9%) received at least 1 line of treatment, with a median of 2 (range 1-10). No significant differences in OS were observed between the 3 time cohorts, with a median overall survival (mOS) of 1.63 years, 1.37 years and 1.57 years in cohorts 1-3, respectively (p=0.12).When comparing across subtypes, the ER+ group faired best with a mOS of 1.96 years (95% CI 1.8-2.1), consistent across time cohorts (p=0.72). This was followed by the HER2+ group with a mOS of 1.53 years (95% CI 1.3-1.7), also consistent across time cohorts (p=0.31). The TNBC group faired worst, with a mOS of 0.67 years (95% CI 0.6-0.8) over time (p=0.87).

Conclusions: Despite advances in systemic therapy since the early 2000s, no meaningful improvements in overall survival were observed over time, regardless of subtype. It remains to be seen if developments since 2013 will lead to gains in overall survival for MBC patients, at a real life, population-based level.

[1]Chia SK, Speers CH, D'yachkova Y, et al. Cancer 2007;110:973-979.

Citation Format: LeVasseur N, Fiorino L, Speers CH, Aparicio M, Lohrisch C, Chia SK. Prognosis and survival in metastatic breast cancer – Ten years in review, a population-based analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-16-05.

[Low protein diet supplemented with ketoanalogues of amino acids in patients with chronic renal insufficiency]

Restricted protein diets in patients with chronic kidney disease have been debated for several decades. In chronic kidney disease as in other chronic diseases, the modulation of the nutritional intake is the object of a certain renewal. It is supported by recent studies that highlight the importance of modulating nutrient intake by diets that are healthier, less rich in animal proteins and richer in plants. The recent reintroduction in France of amino acid supplements and ketoanalogs of amino acids allows the prescription of a very restricted diet. Historical studies have only focused on the relationship between protein intake and renal function degradation. Recent studies on acid loading, bone metabolism or potassium intake allow revisiting the interest of restricted diets. As with any change in eating habits, the selection of patients, information, education and monitoring during the diet are very important and help prevent undernutrition: this is the purpose of this short review.

Structural properties and corrosion resistance of tantalum nitride coatings produced by reactive DC magnetron sputtering

There is a correlation between the corrosion resistance, structure, roughness and the porosity of TaN sputtered films.

Active corrosion inhibition of mild steel by environmentally-friendly Ce-doped organic–inorganic sol–gel coatings

A bi-layer siloxane-methacrylate coating (26 μm) doped with cerium on mild steel combining a barrier effect with self-healing in 3.5 wt NaCl.

[A review of diseases related to the intake of gluten]

Cereals are considered a basic food. Through the development of cooking, the human being has produced high- gluten-content food, so that it could make the most of its nutritional properties. Wheat is becoming one of the key elements of the Mediterranean diet. Amongst gluten- intake-related pathologies- gluten is present mainly in wheat, barley and rye- celiac disease (CD) is the most well-known. CD is a chronic inflammatory condition which affects gastrointestinal tract which develops in genetically predisposed individuals. The most common manifestation of CD is nutrients malabsorption. This protein trigger other pathology, wheat allergy (WA), which is an adverse immunological effect to gluten due to E immunoglobulin. A recent increased in non celiac gluten sensitivity (NCGS) has also been noticed, defined as the emergence of a range of gluten-intake related symptoms in patients for which celiac disease and wheat allergy have been ruled out. This article discusses these three conditions with their phatogenic mecanisms and the different clinic manifestations.

Aryl hydrocarbon receptor-induced adrenomedullin mediates cigarette smoke carcinogenicity in humans and mice

Cigarette smoking (CS) is a leading cause of death worldwide. The aryl hydrocarbon receptor (AHR) is partially responsible for tobacco-induced carcinogenesis although the underlying mechanisms involving early effector genes have yet to be determined. Here, we report that adrenomedullin (ADM) significantly contributes to the carcinogenicity of tobacco-activated AHR. CS and AHR activating ligands induced ADM in vitro and in vivo but not in AHR-deficient fibroblasts and mice. Ectopic transfection of AHR rescued ADM expression in AHR(-/-) fibroblasts whereas AHR blockage with siRNA in wild type cells significantly decreased ADM expression. AHR regulates ADM expression through two intronic xenobiotic response elements located close to the start codon in the ADM gene. Using tissue microarrays we showed that ADM and AHR were coupregulated in lung tumor biopsies from smoker patients. Microarray meta-analysis of 304 independent microarray experiments showed that ADM is elevated in smokers and smokers with cancer. In addition, ADM coassociated with a subset of AHR responsive genes and efficiently differentiated patients with lung cancer from nonsmokers. In a novel preclinical model of CS-induced tumor progression, host exposure to CS extracts significantly elevated tumor ADM although systemic treatment with the ADM antagonist NSC16311 efficiently blocked tobacco-induced tumor growth. In conclusion, ADM significantly contributes the carcinogenic effect of AHR and tobacco combustion products. We suggest that therapeutics targeting the AHR/ADM axis may be of clinical relevance in the treatment of tobacco-induced pulmonary malignancies.

Abstract 2322: Rapid discovery of novel antiangiogenic drugs using a phenotypic profiling platform with high predictive value for preclinical models of cancer

Deregulation of angiogenesis plays a major role in a number of human diseases, most notably cancer. While angiogenesis inhibitors are promising anticancer drug candidates, existing FDA approved therapeutics have shown limited efficacy in the clinic. The majority of angiogenesis inhibitors under clinical development have been designed with the help of high-throughput screening techniques targeting single molecular moieties. These methods have proven effective but it has been long recognized that they lack correlation with activity in preclinical models of cancer which results in high levels of attrition during early stages of drug discovery and phase II clinical trials. We propose that multi-parameter analysis discovery methods are required to capture and translate the tumor angiogenesis complexity into the drug discovery process. Here we introduce a novel high-content cell-specific fluorescence platform for discovery of antiangiogenic agents with highly predictive value for preclinical end points. We have validated this technology by screening the 1970 small molecules of the NCI Developmental Therapeutics Program Diversity Set. This platform features a primary screening based on high content growth and tube formation assays using VEGFR2-nonexpressing, fluorescent-reporter endothelial cells. Over 30 morphological parameters were quantitatively assessed in the tube formation assays in an automated fashion with the newly developed image analysis software AngioApplication. 2.3% (46) of all the small molecules in the library showed growth inhibitory activity, 3.5% (70) significantly blocked tube formation and 0.5% (11) demonstrated both activities. None of the lead compounds were found to interfere with tubulin polymerization or inhibited receptor tyrosine kinase activity. Seven lead compounds were evaluated in a leiomyosarcoma xenograft model of angiogenesis. All showed anti-tumor activity, and two of the compounds (CID 5458317 and CID 429599) blocked tumor growth with comparable efficacy as bevacizumab. An antiangiogenic score computed based on tube formation assessment and gene expression profiling was highly predictive of tumor growth inhibition in vivo. The antiangiogenic mechanism of action of these compounds was validated using tumor onplants on chicken chorioallantoic assays which consistently tracked observations in xenograft models. Intravital microscopy assessment of xenograft tumors treated with CID 5458317 showed massive leakiness and vascular regression of tumor vasculature but not in adjacent normal vasculature. In conclusion, we have developed a drug discovery phenotypic screening platform which shows high predictive value for preclinical models of cancer. Using this platform, several small molecules with novel antiangiogenic mechanisms of action have been identified.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2322. doi:1538-7445.AM2012-2322

Influence of HBcAb positivity in the organ donor in heart transplantation

OBJECTIVE

There is a significant risk of hepatitis B transmission from HBsAg (-), HBcAb (+) donors in liver transplantation, but there is little information about hepatitis B transmission from HBcAb heart donors. The present study examines the influence of HBcAb presence in relation to heart donor acceptance and offers an update of the published studies.

DESIGN

Survey and medical database update from 1994 to October 2011.

SETTING

Spanish heart transplantation teams.

PATIENTS

Not applicable.

STUDY VARIABLES

Acceptance of heart transplant from an HBcAb (+) organ donor.

RESULTS

Twelve out of 15 surveyed teams were seen to vaccinate against HBV, and two quantify HBsAb titers. Seven teams specifically request donor HBcAb status. If the latter proves positive, two do not accept transplantation, two accept if the donor is also HBsAb (+), one selects the receptor under emergency conditions, and three use drug prophylaxis isolatedly or complementary to the above. Only one case of hepatitis B has been reported in a HBcAb (-) and HBsAb (-) receptor that did not receive prophylactic measures. There have been reports of seroconversion of the HBcAb and HBsAb markers, though with an uncertain etiology.

CONCLUSIONS

HBcAb seropositivity influences acceptance of a heart donor, but agreement is lacking. There is limited information on receptor evolution. To date there has been one reported case of hepatitis B after heart transplant. Although rare, an HBcAb (+) donor can harbor occult HBV infection. The risk of infection can be prevented with appropriate HBsAb titers following vaccination or by pharmacological measures.

Abstract A2: Development of a phenotypic profiling platform with high predictive value for the identification of novel antiangiogenic drugs

Deregulation of angiogenesis plays a major role in a number of human diseases, most notably cancer. Although angiogenesis inhibitors are among the most promising anticancer drug candidates, existing FDA approved drugs have shown limited efficacy in the clinic. The majority of angiogenesis inhibitors under clinical development have been designed with the help of high-throughput screening techniques focused on single molecular targets. Although these methods have yielded several candidates, it has been long recognized that a lack of correlation with activity in in vivo preclinical models has resulted in high levels of attrition during the early stages of drug discovery. Here we introduce a novel high-content cell-specific fluorescence platform for discovery of antiangiogenic agents, which we have validated by screening the 1970 small molecules part of the NCI Diversity Set. The platform features a primary screening based on high content growth and tube formation assays using phenotypically defined fluorescent reporter endothelial cells. Tube formation assays were performed using VEGFR2-nonexpressing endothelial cells and quantitatively evaluated in an automated fashion with the newly developed image analysis software AngioApplication. 2.3% (46) of all the small molecules in the library showed growth inhibition activity and 3.5% (70) significantly blocked tube formation. Interestingly, 0.5% (11) of the small molecules showed growth and tube formation inhibitory activity. None of the lead compounds interfered with tubulin polymerization or inhibited receptor tyrosine kinase activity. Seven lead compounds were evaluated in xenograft tumor angiogenesis models. All showed anti-tumor activity, and two of the compounds (CID 5458317 and CID 429599) blocked tumor growth in an in vivo leiomyosarcoma xenograft model of angiogenesis with comparable efficacy as bevacizumab. Gene expression profiling showed that the number of proangiogenic pathways down-regulated in endothelial cells recovered from drug-exposed tube formation assays was predictive of tumor growth inhibition in vivo. High-throughput chicken chorioallantoic assays closely mimicked the efficacy of tested drugs in the tumor xenograft models and supported an antiangiogenic mechanism of action. Histological assessment of xenograft tumors treated with CID 5458317 showed a drastic diminution of their vascular network compared to vehicle treated tumors. Preliminary data using intravital microscopy on a mouse dorsal skin chamber model showed massive leakiness and vascular regression in tumor vasculature exposed to CID 5458317. In conclusion, we have developed a platform for the identification of novel antiangiogenic drugs with high predictive value. Using this platform, several small molecules with potentially novel antiangiogenic mechanisms of action have been identified.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr A2.

Pregnancy-specific glycoprotein 1 induces endothelial tubulogenesis through interaction with cell surface proteoglycans

Pregnancy-specific β1 glycoproteins (PSGs) are the most abundant fetal proteins in the maternal bloodstream in late pregnancy. They are secreted by the syncytiotrophoblast and are detected around day 14 postfertilization. There are 11 human PSG genes, which encode a family of proteins exhibiting significant conservation at the amino acid level. We and others have proposed that PSGs have an immune modulatory function. In addition, we recently postulated that they are proangiogenic due to their ability to induce the secretion of VEGF-A and the formation of tubes by endothelial cells. The cellular receptor(s) for human PSGs remain unknown. Therefore, we conducted these studies to identify the receptor for PSG1, the highest expressed member of the family. We show that removal of cell surface glycosaminoglycans (GAGs) by enzymatic or chemical treatment of cells or competition with heparin completely inhibited binding of PSG1. In addition, PSG1 did not bind to cells lacking heparan or chondroitin sulfate on their surface, and binding was restored upon transfection with all four syndecans and glypican-1. Importantly, the presence of GAGs on the surface of endothelial cells was required for the ability of PSG1 to induce tube formation. This finding indicates that the PSG1-GAG interaction mediates at least some of the PSG1 proposed functions.

[Recommendations for the management of influenza in pediatrics (2009-2010).]

Specific action plans from various institutions, governments and scientific societies have been identified and implemented to combat the A H1N1 2009 influenza virus pandemic. This document sets out the recommendations of the Spanish Association of Pediatrics for the management of influenza in children for influenza season 2009-2010. The risk factors for influenza A H1N1 2009 in pediatric patients, the clinical course, severity and complications are similar to seasonal influenza. In most cases, the diagnosis of influenza will be based on clinical suspicion, without viral subtype differentiation. In a patient with influenza virus infection, the criteria for referral and hospital admission will be based broadly on the signs of clinical severity or complications, regardless of the causative virus. Children with influenza but with no signs of clinical severity or complications do not require antiviral treatment. Physical measures of hygiene and isolation are essential to reduce the transmissibility of the disease. The influenza vaccines in infancy, for both seasonal influenza and for influenza A H1N1 2009, should be directed primarily at patients with risk factors.

Bone loss in diabetic patients with chronic kidney disease

OBJECTIVE

We investigated whether loss of bone is detectable during follow-up of diabetic patients with chronic kidney disease (CKD).

RESEARCH DESIGN AND METHODS

In 40 initially non-dialysed diabetic patients with CKD (isotopic glomerular filtration rate < 60 ml/min/1.73 m(2) or albumin excretion rate > 30 mg/24 h), body composition (DEXA scan) and glomerular filtration rate (GFR determined from (51)Cr-EDTA clearance) were measured at a 2-year interval, and compared by paired t-tests.

RESULTS

The 40 patients, mainly with Type 2 diabetes (n = 28), were men (n = 28), aged 65 +/- 11 years, with diabetes duration 18 +/- 11 years. GFR was initially 38.0 (range 8-89) ml/min/1.73 m(2). CKD progressed during follow-up: eight started haemodialysis and GFR declined in the 32 others (P < 0.05 vs. initial). T-scores for total body (initial -0.61 +/- 1.11, final -1.11 +/- 1.40; P < 0.001) and femoral neck (initial -1.88 +/- 0.15, final -2.07 +/- 0.15; P < 0.05) declined. Ten patients were osteopaenic at baseline (no osteoporosis), whereas most were osteopaenic (n = 21, P < 0.05) and five were osteoporotic at final assessment. The 16 patients who became osteopaenic or osteoporotic during follow-up did not differ from the others for the type of diabetes, age, GFR, albumin excretion rate, HbA(1c), GFR reduction and the requirement for dialysis during follow-up. They were all men (P < 0.01 by chi-squared test), with reduced initial total body T-score (-1.20 +/- 0.82, others -0.32 +/- 1.13; P < 0.05) and a lower body mass index (24.6 +/- 4.3; others 27.7 +/- 4.3; P < 0.05).

CONCLUSION

Bone loss, especially in the femoral neck, is progressive in diabetic patients with CKD.

Transplant Renal Artery Stenosis: Association With Acute Vascular Rejection

BACKGROUND

Transplant renal artery stenosis, the prevalence of which varies from 2% to 12%, is an important cause of hypertension and allograft dysfunction. We sought to determine the clinical characteristics of this disorder, assessing, predisposing factors, establishing treatment options, and examining patient outcomes.

PATIENTS AND METHODS

Among 321 renal allograft recipients between November 1996 and December 2004, six patients were identified with this finding. We analyzed their clinical data before and after treatment compared with the 315 recipients face of the disorder.

RESULTS

The six patients with the disorder were diagnosed within the first year (2 to 8 months; median 5.5 months). All patients displayed renal dysfunction, peripheral edema, and new-onset or uncontrolled hypertension at presentation. Abnormal Doppler findings were observed in 5 (83.3%) patients. The hemodynamically significant stenosis was successfully treated with percutaneous transluminal angioplasty (PTA) in all six. However, 3 (50%) patients displayed recurrent stenosis requiring a second PTA. The mean serum creatinine level decreased from a pre-PTA value of 4.4 +/- 1.8 mg/dL to a 1-month post-PTA value of 2.2 +/- 0.5 mg/dL (P = .027). Patients had no significant improvement in mean systolic and diastolic pressure. Vascular acute rejection episodes were more frequent among the affected than the control group (3/6; 50% vs 18/315; 5.7%; P < .001). No differences were found in age, sex, donor type, etiology of renal disease, immunosuppression, acute tubular necrosis, acute cellular rejection, cold ischemia time, or HLA matching.

CONCLUSION

Transplant renal artery stenosis is a common cause of hypertension and renal allograft dysfunction. Acute vascular rejection is associated with this disorder.

Update on primary HIV-1 resistance in Argentina: emergence of mutations conferring high-level resistance to nonnucleoside reverse transcriptase inhibitors in drug-naive patients

Here we present a survey including 52 drug-naive recently HIV-1-infected subjects from Buenos Aires City and province (79%) and 3 other regions in Argentina (21%). Recent infections were established from previous negative serology (32/52), indeterminate Western blot (12/52), or acute retroviral syndrome after high-risk HIV exposure (8/52) within 9 months before genotyping (median time, 4.2 months). Genotyping was performed from plasma by sequencing both protease and reverse transcriptase. Phylogenetic analysis combined with bootscanning resulted in 21 subtype B sequences and 31 B/F recombinants (RecBF). On protease, minor resistance-related mutations were found in both subtype B and RecBF with low frequencies. The substitution L89M, recently suggested as a resistance-related mutation in some subtype F viruses, was observed in 1 RecBF. On reverse transcriptase, major resistance-related mutations were found in 4 of 52 (7.7%) patients from different health centers: M41L (subtype B) and K103N+/-P225H (1 RecBF and 2 subtype B). The greater than 5% resistance threshold found indicates a need for sentinel resistance surveillances calling for an update in the current resistance testing guidelines in Argentina.