Electromyography data in chronic migraine patients by using neurostimulation with the Cefaly® device.

The objective of this observational study is to report clinical and instrumental results obtained in 23 chronic migraine sufferers treated with transcutaneous neurostimulation with the Cefaly(®) device. The electrom yography (EMG) parameters of the patients monitored before and during neurostimulation with the Cefaly(®) device showed a significant increase in the EMG amplitude and frequency values in the frontalis, anterior temporalis, auricularis posterior and middle trapezius muscles. The Cefaly(®) device could act on the inhibitory circuit in the spinal cord thus causing a neuromuscular facilitation and may help reduce contraction of frontalis muscles.

Factors predicting the time for CD4 T-cell count to return to nadir in the course of CD4-guided therapy interruption in chronic HIV infection.

OBJECTIVE: Our previous studies on CD4-guided therapy interruption (TI) showed that the durations of the first and second TIs were similar if antiretroviral therapy (ART) was resumed at a level of the CD4 cell count similar to or higher than the nadir CD4 T-cell count. Therefore, in a strategy of repeated CD4-guided TI, it is important to know which factors predict the time for the CD4 T-cell count to return to nadir (TRN). METHODS: From a cohort of 125 patients who interrupted ART, 92 patients who reached a CD4 T-cell count similar to the nadir count were included in the study. RESULTS: The median TRN was 12.3 months. In the multivariate analysis, younger age (P=0.011), lower pre-ART HIV RNA (P=0.022) and female gender (P=0.045) were associated with a longer TRN. After TI there were 11 clinical events in the group of patients whose nadir CD4 count was >200 cells/microL. Most of these events occurred when the TI was prolonged beyond the TRN. CONCLUSIONS: The factors predicting the TRN were age, HIV RNA pre-ART and gender. Resumption of therapy at a CD4 cell count similar to the nadir CD4 count appears to protect against the development of clinical events. Given the observational nature of this study, no conclusions can be drawn regarding the possible application of TI in clinical practice.

Plasma viral load concentrations in women and men from different exposure categories and with known duration of HIV infection. I.CO.N.A. Study Group.

CONTEXT: According to recent studies, women have lower plasma HIV RNA concentrations than men. However, these studies did not take into account the duration of HIV infection. OBJECTIVES: To analyze the relationship between viral load and gender among individuals with known date of seroconversion. SETTING: Sixty infectious disease clinics in Italy. DESIGN: Cross-sectional analysis of data collected at enrollment in a cohort study. PARTICIPANTS: Injecting drug users and heterosexual contacts naive to antiretroviral therapy at enrollment (245 men; 170 women). MAIN OUTCOME MEASURES: Plasma HIV RNA concentrations, measured using quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) or signal amplification b-DNA assays before antiretroviral therapy. RESULTS: Plasma HIV RNA concentrations were similar by age and exposure category (p =.80 and p =.39, respectively). Median viral load among women was roughly half that of men (p =.002). The association between viral load and gender remained significant after fitting a two-way analysis of variance (p =.03) and after adjusting for CD4 count, modality of HIV transmission, and age at enrollment in a regression model. Viral load was 0.27 log10 copies/ml (95% confidence interval, 0.05-0.40; p =.01) lower in women (i.e., 50% lower in the raw scale). CONCLUSIONS: Plasma HIV RNA concentrations were found to be lower among women, even when considering the duration of HIV infection. Compared with men, it is possible women should be given highly aggressive antiretroviral therapy at lower HIV-RNA concentrations.

Italian multicentre study of didanosine compassionate use in advanced HIV infection. Italian BMS-906 Study Group.

The aim of the present study, a multicentre trial of didanosine (ddI) compassionate use, was to identify factors associated with a better outcome in patients given ddI monotherapy. Enrolled were 1047 HIV-positive patients intolerant of and/or unresponsive to zidovudine (ZDV) therapy, with CD4+ cell counts of < 200/microliter or AIDS. Didanosine was given at a dose of 250 mg b.i.d. (patients > or = 60 kg) or 167 mg b.i.d. (patients < 60 kg). Clinical examinations and laboratory tests were performed every two months. Endpoints included death, the occurrence of a new AIDS-defining disease, or permanent discontinuation of ddI for a severe adverse event. At entry, the median CD41 cell count was 47/microliter and the median duration of prior ZDV treatment 19 months; 446 patients (43%) were classified as having AIDS. Severe toxicity occurred in 143 subjects (14%); the frequency of pancreatitis was very low (0.2%). The benefit in terms of CD4+ cell counts was greater for patients whose counts exceeded 100/microliter at entry and remained at this level until month 12 in those patients still receiving treatment. Death and/or new AIDS-defining events were observed in 374 cases (36%) over a median follow-up of eight months. AIDS dementia was observed in 11 patients (1%). Multivariate analysis of survival without disease progression showed that the factors associated with a worse outcome include the severity of immunodepression, a diagnosis of AIDS at entry, and a history of both intolerance of and clinical resistance to ZDV. Surprisingly, the patients who had received previous prolonged treatment with ZDV had a better outcome. In conclusion, severely immunodepressed patients previously administered long-term monotherapy may receive a short-term benefit from being switched to another antiretroviral drug.

[Use of esophageal atrial electrogram and an external Thera VDD pacemaker in atrial-triggered ventricular pacing in acute myocardial infarction complicated by total AV block and low cardiac output]. / Uso dell'atriogramma esofageo e di un pacemaker Thera VDD esterno per un paging ventricolare atrioguidato in corso di infarto miocardico acuto complicato da blocco AV totale e bassa portata cardiaca.

Aim of this short report is to present a simple and fast technique to pace in VDD mode patients with acute myocardial infarction associated with third degree AV block and haemodynamic deterioration. VDD pacing was obtained using atrial electrogram recorded by trans-oesophageal catheter and a Medtronic Thera VDD pace-maker as temporary pace-maker.

Community-acquired pneumonia in a cohort of former injection drug users with and without human immunodeficiency virus infection: incidence, etiologies, and clinical aspects.

Although the association among bacterial pneumonia, human immunodeficiency virus (HIV) infection, and injection-drug use seems to have been well established, accurate estimates of the risk of community-acquired pneumonia among HIV-positive and HIV-negative injection-drug users (IDUs) are still needed. To estimate the incidence of pneumonia in a community of former IDUs, we followed 4,236 persons between 1991 and 1994; 1,114 (26.3%) were HIV-positive and 3,122 (73.7%) were HIV-negative. All patients were evaluated for pneumonia by standard criteria, a serum sample was obtained from each participant at least once a year, and laboratory values were monitored. Overall, 149 episodes of pneumonia occurred among HIV-positive patients and 61 among HIV-negative patients; incidence rates were 90.5 and 14.2 (per 1,000 person-years), respectively. The most common etiologic agents were Streptococcus pneumoniae, Chlamydia pneumoniae, and Haemophilus influenzae. Among the HIV-positive former IDUs, there was a 1.37-fold increase in the relative risk of pneumonia for every decrease of 100/mm3 in the CD4 cell count (95% confidence interval, 1.16-1.61). The incidence of community-acquired pneumonia was markedly higher among HIV-positive participants than among HIV-negative ones, a finding similar to that concerning the general population.

Rhodococcus equi infection in HIV-positive subjects: a retrospective analysis of 24 cases.

Rhodococcus equi causes a rare infection in immunocompromised hosts. We describe 24 cases of infection in patients with AIDS-related complex (ARC)/acquired immunodeficiency syndrome (AIDS). Pneumonia was always the first manifestation of R. equi infection, but extrapulmonary involvement was also observed. The main sources of bacteria were sputum, bronchial washings and blood. The strains isolated were mainly susceptible to erythromycin, vancomycin, teicoplanin, rifampicin, imipenem and aminoglycosides. Initial treatment should involve an intravenously administered antibiotic combination therapy including imipenem or vancomycin or teicoplanin, followed by orally administered maintenance combination therapy. Drug combinations should be investigated for serum bactericidal activity in vitro. Surgery does not increase survival time and should only be performed in cases that do not respond to antibiotic treatment. Presumptive risks of infection (contact with horses or farm dust, or cohabiting with people affected by R. equi infection) were present in more than 50% of patients. This finding, and the frequency of bacteria in the sputum, are not sufficient proof of transmission between humans, but do suggest the need for respiratory isolation of patients affected by R. equi pneumonia.

[Bullous pneumopathy and spontaneous pneumothorax. Atypical radiologic patterns of Pneumocystis carinii pneumonia]. / Pneumopatia bollosa e pneumotorace spontaneo. Quadri radiologici atipici della polmonite da Pneumocystis carinii.

Pneumocystis carinii pneumonia (PCP) is certainly the most frequent opportunistic pulmonary infection in AIDS patients. Besides the conventional radiographic features demonstrating bilateral infiltrates and airspace consolidation, atypical radiologic patterns are reported in the literature, which are characterized by spontaneous pneumothorax and by the presence of bullae, cysts and areas of pulmonary cavitation. Forty consecutive PCP patients were investigated, ten of them presenting with atypical radiographic findings: 1 case of spontaneous pneumothorax with no evidence of bullae and 9 cases of bullous lung disease--5 of them complicated by spontaneous pneumothorax. Several pathogenetic hypotheses were considered; lesions evolution and the differential radiologic diagnosis were discussed. As for diagnosis, the value of chest CT scans is emphasized, together with that of HRCT which is extremely valuable to localize, characterize and evaluate bullous lesions and associated parenchymal signs.

[Ventricular stimulation triggered by esophageal atriogram: a new technique of temporary physiologic stimulation in the course of acute myocardial infarct complicated by atrioventricular block and low cardiac output]. / Stimolazione ventricolare triggerata dall'atriogramma esofageo: nuova tecnica di stimolazione temporanea fisiologica in corso di ima complicato da bav avanzato e bassa portata cardiaca.

Advanced atrio-ventricular (AV) block during acute myocardial infarction (AMI) is considered a complicating dysrhythmia as the well as mechanism responsible for occurrence of life-threatening hemodynamic changes. Often, simple VVI pacing can result insufficient in improving the decreased cardiac output. VDD pacing, which preserves atrial contribution, should represent the most effective electrical approach; therefore, it requires intracavitary placement of 2 catheters. In 10 pts (6M, 4F, mean age of 63.8 +/- 6.6 years) with advanced AV block due to AMI (4 inferior, 6 anterior) and without sinus node dysfunction, we performed stable VDD stimulation (mean 16.6 +/- 20.6 hours) using only one catheter positioned in the right ventricle while the atrial impulse, filtered (50-70 Hz) and amplified through a special device, was derived from the esophagus. Such technique is rapid and reliable, avoiding problems associated with atrial sensing and catheterization.

[Increase in blood potassium and subsequent normalization: effects on the electrocardiogram. Case report]. / Aumento della potassiemia e successiva normalizzazione: effetti sull'elettrocardiogramma. Descrizione di un caso.

Significant variations in the ECG have been observed in a female aged 77 with heart failure and chronic atrial fibrillation during an occasional increase in blood potassium followed by normalization. The major phenomena observed during hyperkalemia, due to a severe dehydration, were a transient sinus rhythm with atrio-ventricular block followed by atrial activity disappearance and advent of interventricular and fascicular block. Therapeutic normalization of blood potassium leads to a progressive disappearance of intraventricular and fascicular block, a temporary sinus rhythm and finally the return to atrial fibrillation which was the steady state of the patient before the blood potassium imbalance.

[Clinical and electrophysiological indications for permanent electrostimulation in sick sinus syndrome (author's transl)]. / Indicazioni cliniche ed elettrofisiologiche alla elettrostimolazione definitiva nella malattia del nodo del seno.

In 49 patients with sick sinus syndrome the following electrophysiological parameters were studied: sinus node recovery time and conduction time, atrial and AV nodal refractory periods, atrioventricular and intraventricular conduction. Moreover, pharmacological, vagal and sympathicomimetic stimulation were performed. These data were related to the clinical picture to establish any possible correlation leading to a more specific therapeutical choice. Patients were divided in two groups: group 1, with a prevalence of tachyarrhythmic symptoms and a lesser incidence of syncope, in which cases the sinus node function appeared to be only slightly affected. In group 2 small incidence of tachyarrhythmias and a clear prevalence of syncope with severe impairment of sinusal automaticity and/or sinoatrial conduction were present; AV and IV conduction disturbances were equally distributed in both groups. In more than 1/3 of the cases of the group I arrhythmias were succesfully treated with pharmacological therapy only, with Group 1 A antiarrhythmic agents in most cases. In the other cases of this Group and in all cases of Group II permanent electrical stimulation alone or together with drug therapy was necessary. Long term results with different therapeutical choices and, specifically, with the type of stimulation chosen in individual cases (sequential, rate-programmable ventricular, demand ventricular) are presented.

[Electrophysiological mechanisms of tachyarrhythmias associated with the sick sinus syndrome (author's transl)]. / Meccanismi elettrofisiologici delle tachiaritmie associate a malattia del nodo del seno.

Atrail programmed stimulation (APS) and His bundle recordings were performed in 24 patients with assessed sick sinus syndrome, 14 of whom had previously suffered from bouts of spontaneous paroxysmal tachycardias (Group I) and 10 with no history of previous similar complication (Group II). APS reproduced re-entry arrhythmias in 13 cases of Group I (92%). In 6 cases, junctional reciprocating tachycardia was elicited and the atrioventricular node function curve showed a typical steplike profile, consistent with longitudinal dissociation of the node itself as a cause of reciprocation. In 7 cases with previous paroxysmal atrial tachycardias, APS elicited intra-atrial re-entry arrhythmias. Absolutely no arrhythmia was elicited by APS in the 10 cases of Group II. High incidence of basal prolongation of conduction intervals was observed in both Groups (11 cases in Group I, 6 cases in Group II). Intra-atrial and/or atrio-nodel conduction delays were recognized in all the cases with intra-atrial re-entry arrhythmias. These results suggest that so called bradycardia-tachycardia syndrome should be regarded as an independent clinical form from the sick sinus syndrome, sharing with the latter the sinusal disfunction only. Re-entry mechanisms seems to be mainly responsible for the inititation of paroxysmal tachyarrhythmias: re-entry in the atrium, based on stable conduction delays, is probably correlated with scattered lesions of the same degenerative process affecting the sinus node. On the contrary, the frequent association of sick sinus syndrome with junctional paroxysmal tachycardia and its comples dissociation mechanism of the a-v node, raises the suspicion that, in such cases, two completely different processes are merely coexisting: a degenerative lesion of the sinus node and an anatomical or functional anomaly of a separate portion of the conduction system.