The budget impact of introducing the OMNI® surgical system to a United States health plan for managing mild-to-moderate primary open-angle glaucoma

OBJECTIVES

Minimally invasive glaucoma surgery devices fill an unmet need in the treatment paradigm between topical intraocular pressure medicines and more invasive filtration procedures. This study evaluated the adoption of The OMNI® Surgical System with or without cataract surgery in primary open-angle glaucoma patients.

METHODS

A budget impact analysis estimated costs before and after adoption of OMNI® to a hypothetical US health plan with 1 million Medicare-covered lives over two years. Model input data were derived from published sources and development of the model included primary research with key opinion leaders and payers. The model compared total annual direct costs for OMNI® versus other treatment options (medications, other minimally invasive surgical procedures, selective laser trabeculoplasty) to calculate budget impact. A one-way sensitivity analysis was conducted to assess parameter uncertainty.

RESULTS

Increased adoption of OMNI® resulted in budget neutrality over the two years with a decrease in total costs of $35,362. Per member per month incremental costs were $0.00 when used without cataract surgery and yielded cost savings of -$0.01 when used with cataract surgery. Sensitivity analysis confirmed model robustness and identified surgical center fee variability as a key driver of costs.

CONCLUSION

OMNI® is budgetary efficient from a US payer perspective.

Systematic Literature Review of Clinical, Economic, and Humanistic Outcomes Following Minimally Invasive Glaucoma Surgery or Selective Laser Trabeculoplasty for the Treatment of Open-Angle Glaucoma with or Without Cataract Extraction

Introduction

Selective laser trabeculoplasty (SLT) and minimally invasive glaucoma surgery (MIGS) are increasingly used options for mild-to-moderate open-angle glaucoma (OAG) care. While most MIGS devices are indicated for use in combination with cataract surgery only, with phacoemulsification playing a role in lowering IOP, newer technologies can also be used as standalone glaucoma surgery.

Methods

This systematic literature review (SLR) aimed to assess the clinical, economic, and humanistic outcomes of MIGS and SLT for the treatment of OAG and was conducted according to PRISMA guidelines. Studies that assessed MIGS or SLT in at least one treatment arm versus any other glaucoma treatment in adults with mild-to-moderate OAG were included. Clinical, humanistic (health-related quality of life [HRQoL] and patient burden), and economic data were extracted, and the methodological quality of included studies was evaluated.

Results

A total of 2720 articles were screened, and 81 publications were included. Fifty-eight reported clinical outcomes. The majority assessed iStent or iStent inject (n=41), followed by OMNI (n=9), gonioscopy-assisted transluminal trabeculotomy (GATT) or the Kahook Dual Blade (KDB) (n=7), Hydrus (n=6), SLT (n=5), Xen Gel Stent (n=2), PreserFlo (n=1), and iTrack (n=1). IOP reduction was observed across prospective studies, varying from -31% to -13.7% at month 6 and from -39% to -11.4% at year 1 versus baseline. Most adverse events were transient and non-serious. Limited humanistic and economic data were identified.

Conclusion

Given their established efficacy and safety, there is a rationale for wider use of MIGS in mild-to-moderate OAG. Of the MIGS devices, iStent and OMNI have the largest clinical evidence base supporting their sustained effectiveness.

Outpatient parenteral antibiotic therapy in the elderly: an Italian observational multicenter study

Bacterial infections are the most frequent cause of hospitalization in elderly patients. In the early eighties, the advantages of Outpatient parenteral Antibiotic therapy (OPAT) were identified in the United States, and suitable therapeutic programs were established. In order to understand the different ways of managing OPAT, a National OPAT Registry was set up in 2003 in Italy. This study analyzes data concerning bacterial infections in 176 elderly patients including demographics, therapeutic management, clinical response, and side-effects. Bone and joint infections (48.9%) and skin and soft tissue infections (27.8%) were the most common infections treated with OPAT. Teicoplanin (28.9%) and ceftriaxone (22.1%) were the top two antibiotics chosen. OPAT was mainly performed at a hospital infusion center (52.8%). The clinical success rate was high and side-effects were low (12.6% of cases). Management of bacterial infections in the elderly with an outpatient program is effective and safe.

Outpatient parenteral antibiotic therapy for bone and joint infections: an italian multicenter study

In the early eighties, the advantages of outpatient parenteral antibiotic therapy (OPAT) (reduced costs, no hospitalization trauma in children, no immobilization syndrome in elderly, reduction in nosocomial infections by multiresistant organisms) were identified in the United States, and suitable therapeutic programs were established. Currently, more than 250,000 patients per year are treated according to an OPAT program. In order to understand the different ways of managing OPAT and its results, a National OPAT Registry was set up in 2003 in Italy. Analysis of data concerning osteomyelitis, septic arthritis, prosthetic joint infection and spondylodiskitis, allowed information to be acquired about 239 cases of bone and joint infections, with particular concern to demographics, therapeutic management, clinical response, and possible side effects. Combination therapy was the first-line choice in 66.9% of cases and frequently intravenous antibiotics were combined with oral ones. Teicoplanin (38%) and ceftriaxone (14.7%), whose pharmacokinetic/pharmacodynamic properties permit once-a-day administration, were the two top antibiotics chosen; fluoroquinolones (ciprofloxacin and levofloxacin) were the most frequently utilized oral drugs. Clinical success, as well as patients' and doctors' satisfaction with the OPAT regimen was high. Side-effects were mild and occurred in 11% of cases. These data confirm that the management of bone and joint infections in an outpatient setting is suitable, effective and safe.

Predictors of Clinical Progression among HIV-1–Positive Patients starting HAART with CD4+ T-cell Counts ≥200 cells/mm3

Background

Baseline and follow-up predictors of new AIDS-defining events (ADE) or death among patients who started HAART with CD4+ T-cell counts ≥200 cells/mm3 have rarely been assessed simultaneously.

Methods

A prospective observational cohort study (1996–2002) is reported. HIV-infected patients initiating HAART with a CD4+ T-cell count ≥200 cells/mm3 were studied. Baseline and time-varying factors were tested for the prediction of new ADE/death using Cox regression models.

Results

A total of 896 subjects were studied over a median of 5.1 years. The incidence of a new ADE was 1.6 (95% confidence interval 1.3–2.1) per 100 person-years. Among baseline factors, higher CD4+ T-cell counts before HAART were associated with lower risk of ADE/death, but not after adjustment for time-varying factors. On a multivariable analysis including both baseline and time-varying covariates, longer delay from HIV diagnosis to HAART was an independent predictor of ADE/death (per year, hazard ratio [HR] 1.06; P=0.025) and was independent of CD4+ T-cell count before treatment. Longer time spent with HIV RNA <400 copies/ml (per month, HR 0.96; P=0.003) and higher latest CD4+ T-cell count (per log2 cells/mm3, HR 0.65; P<0.001) were found to be protective.

Conclusions

Patients with higher CD4+ T-cell counts before HAART initiation had a better prognosis. However, except for the delay in starting HAART, viro-immunological evolution outweighed the effect of baseline factors. Moreover, suppressing HIV replication for as long as possible could improve the clinical outcome. Prospective randomized clinical trials to assess the optimal timing of HAART initiation are both feasible and urgently needed.

Evolution of HVR-1 Quasispecies after 1-Year Treatment in HIV/HCV-Coinfected Patients According to the Pattern of Response to Highly Active Antiretroviral Therapy

Hepatitis C virus (HCV) variability is mainly attributed to the ability of the virus to respond to host immune pressure, acting as a driving force for the evolution of quasispecies. This study was aimed at studying the changes in HVR-1 heterogeneity and the evolution of HCV quasispecies in HIV/HCV-coinfected patients according to the pattern of response to highly active antiretroviral therapy (HAART).

Sixteen HIV/HCV-coinfected patients harbouring HCV genotype 1 and who had been on HAART for at least 1 year, 8 showing increasing CD4+T-cell counts (immunological responders) and 8 showing a stable or decreasing CD4+ T-cell counts (immunological non-responders), were selected from a prospective cohort study.

After 1 year of HAART, 11 patients showed HIV viral load <2.6 log10 cp/ml (virological responders), and 5 showed HIV viral load above this value (virological non-responders). Plasma samples, collected before starting therapy and after 1 year of HAART, underwent clonal sequence analysis for HVR-1 region of HCV. Non-synonymous/synonymous substitutions ratio (Ka/Ks), aminoacidic complexity (normalized Shannon entropy) and diversity (p-distance), were considered as parameters of quasispecies heterogeneity. After 1 year of HAART, heterogeneity of HVR-1 quasispecies significantly decreased in virological non-responders, whereas the heterogeneity tended to increase in virological responders. The differences in the evolution were less stringent, when considering immunological response. On the other hand, profound qualitative modifications of HVR-1 quasispecies were observed only in patients with both immunological and virological HAART response.

On the whole, these findings suggest that, in patients undergoing HAART, the extent of HCV variability and the evolution of HVR-1 quasispecies is influenced by the pattern of response to antiretroviral therapy.

Open, Randomized, Multicentre Italian Trial on Peg-Ifn plus Ribavirin versus Peg-Ifn Monotherapy for Chronic Hepatitis C in HIV-Coinfected Patients on Haart

Background

Chronic hepatitis C is common and aggressive in HIV-positive patients, so the development of a well-tolerated HCV therapy is a priority. We evaluated the efficacy and safety of pegylated interferon α2b (PEG-IFN) plus ribavirin (RBV) versus PEG-IFN monotherapy in HIV/HCV-coinfected patients undergoing highly active antiretroviral therapy (HAART), and analysed the predictive factors of response.

Methods

An Italian, multicentre, open-label trial including 135 coinfected patients, randomized to PEG-IFN 1.5 μg/kg/week plus RBV 400 mg twice daily ( n=69, arm A) or PEG-IFN 1.5 μg/kg/week ( n=66, arm B) for 48 weeks. We assessed the predictive values of early virological response (EVR) at week 8 (HCV-RNA drop >2 log10 compared with baseline or undetectable levels) on sustained virological response (SVR).

Results

Fifty-five patients (28 from arm A and 27 from arm B) completed 48 weeks of therapy. At the end of treatment, 20/28 patients in arm A and 11/27 in arm B had HCV-RNA <50 IU/ml. In a per-protocol analysis, SVR was reached by 54% of patients in arm A (genotype 2–3, 11/16; genotype 1–4, 4/12) and 22% in arm B (genotype 2–3, 3/15; genotype 1–4, 3/12). In an intention-to-treat analysis, the SVR was 22% in arm A (genotype 2–3, 11/32; genotype 1–4, 4/37) versus 9% in arm B (genotype 2–3, 3/32; genotype 1–4, 3/34). The best predictors of SVR were the use of combination therapy, infection with HCV genotype 3 versus genotype 1, and EVR at week 8. Thirty patients (15 from arm A and 15 from arm B) dropped out of the trial prematurely due to side effects. The positive predictive value of EVR at week 8 was 65%, the negative predictive value was 86%.

Conclusions

PEG-IFN plus RBV can be considered a solid option for the treatment of HIV/HCV-coinfected patients. The key to successfully improving efficacy is strong compliance through strict overall patient monitoring, in order to best manage drug toxicity. EVR assessment at week 8 may become a useful stategy in the management of therapy.

Response to Haart and Gb Virus Type C Coinfection in a Cohort of Antiretroviral-Naive HIV-Infected Individuals

The prognostic role of GB virus type C (GBV-C) viraemia in HIV-infected subjects treated with highly active antiretroviral therapy (HAART) is still undefined, The aim of this analysis is to assess the relationship between GBV-C infection and response to antiretroviral therapy among HIV-infected subjects initiating HAART when antiretroviral-naive.

A prospective, observational study of 400 HIV-infected patients with measurements of GBV-C RNA, hepatitis C virus (HCV) antibodies and HCV RNA determined from plasma stored prior to HAART initiation, Time to virological (achieving HIV RNA ≤500 copies/ml) and immunological success (a CD4+ count increase of ≥200cells/μl), and the time to virological relapse (confirmed HIV RNA >500 copies/ml) were assessed by Kaplan-Meier methods and Cox proportional hazard regression model.

Of the subjects, 117 (29.3%) were GBV-C positive and, overall, 351 (87.8%) patients achieved virological success, After controlling for a number of confounders including HCV RNA, GBV-C viraemic patients experienced a significantly lower risk of HIV rebound than those who were GBV-C negative [relative hazard (RH)=0.56, 95% CI: 0.34–0.93, P=0.03], Conversely, the probability of achieving initial virological success or CD4+ count response after HAART did not differ between GBV-C-negative and -positive subjects, These results suggest that GBV-C coinfection may play a role in determining the rate of HIV rebound possibly by competing with HIV replication after HIV load has been successfully suppressed by HAART.

Variability in the Interpretation of Transmitted Genotypic HIV-1 Drug Resistance and Prediction of Virological Outcomes of the Initial Haart by Distinct Systems

High level HIV-1 drug resistance in recently infected treatment-naive individuals correlates with sub-optimal virological responses to highly active antiretroviral therapy (HAART). To determine whether genotypic HIV-1 drug resistance in chronic naive patients, as interpreted by various systems, could predict the virological outcomes of HAART, isolates from patients enrolled in a prospective observational cohort (ICoNA) prior to treatment start were genotyped. Genotypic susceptibility scores (GSS) assigned to the initial HAART regimens using the interpretations of pre-therapy resistance mutations by 13 systems were related to virological outcomes. Of 415 patients, 42 (10%) had at least one major resistance mutation. According to the different interpretations, 1.9–20.5% of patients had some level of resistance to at least one drug in the initial regimen. In multivariable analysis, GSS from two systems significantly predicted the time to virological success: Rega 5.5, for each unit increase in GSS adjusted relative hazard (RH) 1.86 [95% confidence intervals (95% CI): 1.15–3.02] and hivresistanceWeb v3, RH 1.87 (95% CI: 1.00–3.48). With three other systems, GSS showed a trend towards a significant prediction of success: Retrogram 1.6, RH 2.33 (95% CI: 0.98–5.53), Menéndez 2002, RH 2.36 (95% CI: 0.97–5.72) and Stanford hivdb, RH 2.06 (95% CI: 0.94–4.49). Genotypic resistance testing coupled with adequate interpretation in chronic naive patients can usefully identify those at risk of sub-optimal virological response to HAART.

The Management of Hepatitis B Virus/HIV-1 Co-Infected Patients Starting Their First Haart Regimen. Treating Two Infections for the Price of One Drug?

We examined the impact of a lamivudine-containing highly active antiretroviral therapy (HAART) regimen on 164 hepatitis B virus/HIV co-infected individuals starting their first HAART. Lamivudine-treated patients (accounting for 73% of the study population) showed a significantly lower level of alanine aminotransferase over follow-up [–81.1 mU/ml mean difference; 95% confidence intervals (95% CI): –30.3; –131.7, P=0.003] and a significantly reduced risk of liver-related morbidity/mortality [Relative hazard (RH)=0.07; 95% CI: 0.01–0.38, P=0.002] than those starting a lamivudine sparing-regimen.

Benefits of a rapid HIV test for evaluation of the source patient after occupational exposure of healthcare workers

Rapid human immunodeficiency virus (HIV) testing for the management of occupational exposure of healthcare workers significantly decreased the number of anti-retroviral post-exposure prophylaxis regimens started whilst awaiting HIV test results. The study confirmed an equivalent performance of the rapid test in comparison with HIV enzyme immunoassay, and suggests it is cost-effective. In addition, two other potential benefits emerged: reducing the number of source patients who remain untested and increasing the number of occupational exposures reported.

[The community-acquired pneumonia: appropriateness of the admissions, risk factors and therapy]

In a clinical and epidemiological study used Fine's Pneumonia Severity Index to determine the appropriateness of the hospitalisation of patients with community acquired pneumonia in the Internal Medicine Department of a hospital in Northern Italy. Risk factors and antibiotic treatment were checked against recent international guidelines. The study shows that 20% of the admissions were to be not appropriate. The principal risk factors were old age and such the co-morbidities heart failure, chronic cerebral diseases and COPD. In the home setting macrolides are less used than the new fluoroquinolones respirators. In the hospitals arrangements, b-lactams are still highly used, perhaps because of the high percentage of elderly patients. The data currently available suggest that some new fluoroquinolones such as levofloxacin are quite effective, presenting a broad spectrum of action, high bioavailability and good tolerability. Sequential therapy with this antibiotic leads to shorter hospitalisation times.

[Current epidemiological and clinical features meningitis in a northern Italian area]

Objectives: To study etiological, epidemiological and clinical features of 97 cases of acute meningitis. Methods: Ninety-seven cases of acute meningitis were examined in adult HIV-negative patients admitted to the Infectious Diseases Unit of the Azienda Ospedale-Universita S. Anna in Ferrara. Demographic, etiological, epidemiological and clinical data were analyzed. Results: All cases were divided into two groups according to the macroscopic aspect of cerebrospinal fluid (CSF): purulent CSF (50 cases) or non-purulent CSF (47 cases). Purulent CSF meningitis more frequently affected male patients (64% vs 47%) and older patients (average 52 vs 44 years). The main epidemiological features in both groups were underlying bacterial diseases (i.e. otomastoiditis and/or sinusitis in 50% of pneumococcal meningitis) and iatrogenic immunodeficiency. From a clinical point of view the following alterations in the state of consciousness (stupor, confusion and coma) were most frequently found in purulent meningitis. The following non purulent forms of meningitis were diagnosed: 5 tubercular, 3 viral infections, 2 by Listeria monocytogenes, 1 by Entoameba histolytica, 1 by Cryptococcus neoformans and 35 (74,4%) unknown causes. Purulent meningitis were: 20 (40%) Streptococcus pneumoniae, 10 Neisseria meningitidis, 3 Staphylococcus aureus, 2 Escherichia coli, 1 Haemophilus influenzae and 1 Pseudomonas aeruginosa; 13 cases were unidentified. From 1989 to 1993 and from 1994-98 both groups of meningitis increased; respectively from 17 to 30 cases for non-purulent meningitis and from 18 to 32 cases for purulent meningitis. Meningitis due to Streptococcus pneumoniae increased from 27.7% to 46.8% during the period 1994-98. Conclusions: The study shows the high incidence of pneumococcal meningitis, during 1994-98, because a large number of patients with sinusitis and otomastoiditis were observed. The incidence of meningococcal meningitis appears stable. These data confirm the importance of timely diagnosis and correct therapy for such infections with reserved prognosis.

Invasive Aspergillosis in Italian AIDS patients

BACKGROUND

We studied the prevalence, epidemiological features, symptoms, diagnosis, treatment and outcome of invasive aspergillosis in AIDS patients in Italy.

PATIENTS AND METHODS

All patients affected by both aspergillosis and AIDS hospitalized between January 1986 and April 1997 (before highly-active antiretroviral therapy, HAART) in four Italian Department of Infectious Disease. Patients were included in the study only if culture, cytology or histology showed firm evidence of Aspergillus infection. Invasive aspergillosis was defined as the presence of characteristic, closely septate hyphae with repeated acute angle branching in either biopsy materials or percutaneous aspirates from tissues other than the lung. Hyphae were identified using hematoxylin-eosin and methenamine silver stain.

RESULTS

During the study, 54 out of 2,614 patients admitted with AIDS showed aspergillosis (2.1%). The disease usually occurred in patients with < 50 CD4 cells/mm(3). Aspergillosis was associated with neutropenia and steroid treatment. Nonspecific symptoms were frequently encountered. Fever and cough were both present in > 70% of the cases of pulmonary aspergillosis. Biopsy specimens were analyzed for definitive diagnosis. Invasive aspergillosis is usually treated with amphotericin B, but in 90% of the cases this did not prevent death.

CONCLUSION

In AIDS patients with neutropenia and long-term steroid therapy, it is important to consider invasive aspergillosis in the differential diagnosis of opportunistic infections.

Suicide probability and psychological morbidity secondary to HIV infection: a control study of HIV-seropositive, hepatitis C virus (HCV)-seropositive and HIV/HCV-seronegative injecting drug users

BACKGROUND

Suicide ideation and psychological morbidity among HIV-positive patients has been the object of intense research. No study has investigated this area among injecting drug users (IDUs) infected with HIV and those infected with the hepatitis C virus (HCV), which has the same patterns of transmission of the HIV and may favour HIV replication and, possibly, HIV disease progression.

METHODS

In order to examine the prevalence and characteristics of suicide ideation and psychological morbidity associated with HIV and HCV infection in IDUs, a sample of HIV+ (n=81), HIV-/HCV+ (n=62) and HIV-/HCV- (n=152) subjects completed the Suicide Probability Scale (SPS), The Brief Symptom Inventory (BSI) and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

No difference was found between the groups as far as the mean scores on SPS and the risk of suicide (no-low risk category: 70.7% HIV+, 56.09% HCV+, 65.6% HIV-/HCV-). Estimated psychological morbidity (BSI) (26.9% HIV+, 27.1% HCV+, 25.4% of HIV-/HCV-) and BSI and HADS scores were comparable across the groups.

CONCLUSIONS

Suicide ideation, psychological morbidity and anxiety and depression symptoms seemed not to be directly influenced by HIV-serostatus. Careful assessment of psychological symptoms and suicide ideas among IDUs, as a vulnerable segment of population at risk of HIV and HCV infections, needs to be routinely carried out in clinical settings.

Illness behavior, emotional stress and psychosocial factors among asymptomatic HIV-infected patients

BACKGROUND

Over the last years the way in which patients with chronic physical illness respond to their illness (illness behavior) has been explored by several studies. This study sought to examine characteristics of illness behavior and to investigate the association between illness behavior and psychosocial and clinical variables among asymptomatic HIV-infected subjects.

METHODS

Seventy-three asymptomatic HIV+ outpatients completed self-report questionnaires to evaluate illness behavior (Illness Behavior Questionnaire), psychological stress symptoms (Brief Symptom Inventory), personality variables (External Locus of Control and Courtauld Emotional Control Scales) and social support (Social Provision Scale).

RESULTS

Psychological morbidity ('caseness' = 34%) was associated with a pattern of illness behavior characterized by conviction of disease progression, irritability, dysphoria, psychological perception of illness and low denial. Individual capacity to express emotions, adequate levels of social support and low levels of depression, as well as clinical variables (high number of CD4+ cells, recent notification of HIV infection and nonintravenous drug use category) influenced a more adaptive illness behavior. Psychological stress and low CD4+ cell count were the main predictors of the affective dimension of illness behavior.

CONCLUSIONS

Psychosocial variables resulted to influence the tendency to interpret illness in a nonadaptive way in asymptomatic HIV-infected subjects. Such variables merit to be routinely examined within the doctor-patient relationship in AIDS clinics.

Coping styles and psychosocial-related variables in HIV-infected patients

The study examined the relationship between coping and psychosocial variables (psychological stress symptoms, locus of control, emotional repression, and social support) among 108 human immunodeficiency virus (HIV)-infected patients. The authors administered several tests, including one that measures fighting spirit and degree of hopelessness, to assess each patient's individual coping style. The patients who were adjusting well to their HIV-positive status tended to have a higher level of fighting spirit and lower degree of hopelessness than those patients who were not adjusting well to their HIV-positive status. A coping style based on incapacity to face and confront HIV infection was associated with symptoms of psychological stress, repression of anger, external locus of control, and low social support in the latter group. These patients showed symptoms indicating maladjustment to HIV infection (43% of the sample) and differed from the "noncases" (the well-adjusted patients) in that the former group reported inadequate coping responses (lower fighting spirit and higher hopelessness, fatalistic attitude, and anxious preoccupation) and poorer social support, and had a greater tendency to repress anger and express sadness. The data support the hypothesis that coping with HIV infection is a complex phenomenon involving multiple and interacting variables. Interventions aimed at improving the coping style for many HIV patients are needed.

90K (Mac-2 BP) predicts CD4 decline in human immunodeficiency virus-infected patients with CD4 counts above 200 x 10(6) cells/L

OBJECTIVE

To evaluate the ability of serum levels of 90K, previously reported as a progression marker of human immunodeficiency virus infection, to predict the future rate of CD4 lymphocyte decline.

DESIGN

Retrospective analysis of data from outpatients enrolled in a multi-institutional study.

PATIENTS

One hundred five human immunodeficiency virus-positive intravenous drug users who had at least six serial CD4 lymphocyte measurements and starting CD4 levels of 200 x 10(6) cells/L or higher.

MAIN OUTCOME MEASURE

Rate of CD4 lymphocyte decline.

RESULTS

During a median follow-up of 28 months (range, 20-36 months), the estimated loss of CD4 cells in the whole patient population was 3.4 x 106 cells/L per month (P = .0045). Subjects who were on zidovudine treatment at study entry showed an average loss of 3.8 x 10(6) cells/L per month, significantly higher than in untreated subjects (P = .02), but similar to the loss observed for those requiring initiation of treatment during the course of the study. At baseline, 56 subjects had 90K levels of 10 microg/mL or less, and 49 had more than 10 microg/mL. The rate of CD4 decline in the high-90K group was approximately 5 x 10(6) cells/L per month (P < .0015), whereas in the low-90K group it was not different from zero (P = ns). No difference emerged in the rate of CD4 decline when subjects were stratified according to baseline 90K levels and zidovudine treatment, beta2-microglobulin, or neopterin serum levels.

CONCLUSION

90K serum levels are predictive of CD4 decline.

Acute liver injury related to the use of niperotidine

BACKGROUND/AIMS

H2-receptor antagonists are widely used for the therapy of peptic disease, since they ensure a protracted and intense inhibition of gastric acidity. Niperotidine (piperonyl-ranitidine) is a new H2 blocking agent recently proposed for clinical use.

METHODS

Twenty-five cases of acute hepatitis associated with the use of niperotidine were reported in Italy between March and August 1995. Intercurrent viral infections, recent drug and alcohol consumption and blood transfusions were excluded as causes.

RESULTS

All patients showed an increase in the parameters of liver cell injury and the clinical symptoms of acute hepatitis. After withdrawal of the drug, all patients showed a good outcome, except one who developed a fulminant hepatitis and died from digestive tract bleeding.

CONCLUSIONS

The absence of other causes of acute liver injury suggests that the observed liver injury may be a niperotidine-adverse reaction. Moreover, the lack of a relationship between the dose of the drug and the degree of liver damage, the variable latent period and the rarity and unpredictability of the injury are suggestive of an idiosyncratic reaction.

The 90K tumor-associated antigen and clinical progression in human immunodeficiency virus infection

We investigated the possibility that a secreted glycoprotein of approximately 90,000 daltons, termed 90K and identified as a member of the protein superfamily characterized by the scavenger receptor cysteine-rich (SRCR) domain, might have value as a predictor of progression to acquired immunodeficiency syndrome (AIDS) in subjects infected with the human immunodeficiency virus (HIV). Among 488 HIV-seropositive intravenous drug users with a median follow-up of 32.5 months, high levels of serum 90K at baseline proved to be a significant predictor of faster progression to AIDS, either as a continuous variable (log 90K; p < 0.0001) or as a dichotomous variable with an optimized cutoff point of 30 U/ml (p < 0.00001). Analysis of 90K in relation to known prognostic factors found an association with CD4 count, beta 2-microglobulin, and p24 antigen but none with neopterin. In multivariate analysis, the baseline 90K level was an independent predictor of AIDS. As compared with subjects with low levels of 90K, the relative risk of developing AIDS was 3.5 (95% CI 1.9-6.5) among those with high levels of 90K. The predictive value of 90K was maintained after stratification by baseline CD4 count: among subjects with > or = 500 x 10(6)/L CD4 cells, the proportion in whom AIDS developed was 10.5% for those with 90K levels < or = 30 U/ml as compared with 20% for those with 90K above the cutoff point (p = 0.006). Serum 90K is an independent predictor of the risk for progression to AIDS in HIV-infected subjects, including those whose CD4 counts have not fallen.

Elevated serum levels of a 90,000 daltons tumor-associated antigen in cancer and in infection by human immunodeficiency virus (HIV)

Levels of a 90,000 daltons monoclonal antibody-defined tumor-associated antigen, termed 90K, were measured in the serum from 649 patients with various types of cancer and 1215 patients infected by the human immunodeficiency virus (HIV). Significantly increased 90K serum levels (12.1 +/- 0.5 U/ml) were found in cancer patients with respect to healthy controls (5.7 +/- 0.3 U/ml), with the highest levels in neoplasms of the breast, lung and gastrointestinal tract. In 355 patients with breast cancer, the elevation of serum 90K levels was more pronounced at advanced stages of disease. Mean levels of 90K for 1215 HIV-infected subjects (21.2 +/- 0.8 U/ml) were significantly higher than controls and cancer patients, and the levels progressively increased with disease worsening from asymptomatic infection to full blown AIDS. These data suggest that 90K is not merely a tumor-associated antigen and lead us to postulate it to be a signalling molecule whose production might be related to the immune deficit caused by pathogenetic events such as neoplastic progression and virus infection.

Reduced expression of macrophage-associated antigens on alveolar mononuclear phagocytes from acquired immunodeficiency syndrome

In this study we evaluated the phenotype of alveolar mononuclear phagocytes recovered from the bronchoalveolar lavage fluid of 24 patients with human immunodeficiency virus infection (AIDS-related complex 8 patients. AIDS 16 patients) and 8 healthy individuals by using a panel of monoclonal antibodies known to react with tissue macrophages, in combination with a flow cytometer. The results showed that 90% of patients with AIDS present a marked reduction in the expression of several antigenic determinants (in decreasing order: CD68, CD36, CR1, CD11c, HLA-DR). The levels of antigen expression by flow cytometry seem to decline with disease progression, showing the most dramatic perturbations in patients with full-blown AIDS associated with pulmonary infections (especially Pneumocystis carinii pneumonia) and lower peripheral CD4 lymphocyte counts. In contrast, patients with AIDS-related complex or AIDS without histological or cultural evidence of pulmonary involvement showed, respectively, only minimal or medium antigenic decreases. However, only a minor proportion (16%, 20%, 20%, 25%, and 25% respectively) of human immunodeficiency virus infected patients (mostly with AIDS) had a significant reduction of the levels of CD4, CD14, CD45R, CD11b, and CD16 antigens in the alveolar macrophages. Since macrophages play a central role in the pathogenesis of AIDS, it may be postulated that the loss of various phenotypic markers on alveolar mononuclear phagocytes (some of them known for their important immunoregulatory actions) could have an important part in the pathogenesis of human immunodeficiency virus induced immunosuppression, and thereby condition the abnormal susceptibility to pulmonary diseases typical of human immunodeficiency virus-infected patients.

[Incidence of giardiasis in adults patients with acute enteritis]

The Authors report the findings of a perspective study carried out in 214 cases of acute diarrhoea to estimate the presence of giardia intestinalis infections. The incidence of 3.2% has been discussed on the bases of recent epidemiological advances.

Treatment of cerebral malaria by erythrocyte exchange

A 33-years-old male presented with a severe malaria, caused by a chloroquine resistant strain of Plasmodium falciparum. The number of parasitized erythrocytes reached 20% and the patient had cerebral complication. During the second hospital day, an erythrocyte exchange was performed as an in addition to chemotherapy. The patient's clinical condition improved and the parasitemia disappeared. The erythrocyte exchange is recommended in severe malaria, when parasitemia greater than 10%, with or without cerebral, renal or blood coagulation complications.

[Campylobacter pylori colonization and gastroduodenal pathology]

355 patients suffering from dyspepsia with an endoscopic pathological picture were examined. Campylobacter pylori was sought histologically and by culture. Histological and cultural results were compared. There were no bacteria on the gastric mucosa of 46 patients who had no histopathological evidence of lesions. Cultural studies were performed in 40 cases on endoscopic instruments used during the examination, before and after standard sterilization. Campylobacter pylori was found on the gastric mucosa of 224 patients (63.09%); 91.93% with duodenal ulcer; 71.87% with gastric ulcer; 54.23% with erosive duodenitis; 56.71% with erosive gastritis and 54.81% with chronic gastropathy. The agreement between the two techniques was 75.39%, with a male prevalence (p = 0.05). Campylobacter pylori was present on the gastric mucosa of 10.86% of patients without histopathological evidence of lesions. Standard sterilization with alkyl-dimethyl-benzyl ammonium eliminated the campylobacter in 100% of cases.

[Pneumocystosis]

On the basis of personal experience, the microbiological, epidemiological, clinical and therapeutic features of Pneumocystis carinii pneumonia are analysed.

[Zinc and lymphocyte subsets in patients with HIV infection]

Serum zinc levels were assayed in patients with AIDS and related syndromes, using spectrophotometry and atomic absorption. Statistical data have shown that serum zinc levels, in addition to being significantly lower (p less than 0.001) among different groups and controls, decrease progressively with the worsening of the clinical and immunological picture from LAS to AIDS. Serum zinc levels in patients with AIDS and ARC have, moreover, been demonstrated to be related (r = 0.8240; p less than 0.001) to the lymphocyte subset CD4 helper-induced. These results suggest that serum zinc determination and possibly zinc therapy might be reasonably considered in the management of patients with symptoms of HIV infection.