Risk factors and clinical characteristics associated with hospitalization for community-acquired bacterial pneumonia in HIV-positive patients according to the presence of liver cirrhosis.

BACKGROUND: Community-acquired bacterial pneumonia (CABP) represents an important cause of morbidity and mortality for cirrhotic and HIV-infected patients, respectively. However, little is known on CABP in HIV-positive patients with cirrhosis. A study was performed to describe the clinical features and factors predictive of mortality and prolonged hospitalization in cirrhotic HIV-infected patients with a diagnosis of CABP. METHODS: Demographic and clinical characteristics of cirrhotic HIV-positive subjects, hospitalized for CABP in our department from June 2000 to December 2006, were compared with those of non-cirrhotic HIV-infected patients with the same diagnosis hospitalized from June 2000 to November 2001. Variables with p < 0.10 in univariate analysis were tested for their predictive value for mortality and length of hospitalization with uni- and multivariate logistic regression analysis. RESULTS: Twenty-nine cirrhotic and 73 non-cirrhotic HIV-positive patients with CABP were compared. Age and alcohol abuse were significantly higher in cirrhotics. At hospital admission, cirrhotic patients had more frequently mental status alterations (7.26 [2.21-23.82], p = 0.001) and milder symptoms and signs (temperature > 37.5 C: 0.27 [0.10-0.75], p = 0.01; respiratory rate > 20: 0.34 [0.13-0.92], p = 0.033; systemic inflammatory response syndrome (SIRS): 0.39 [0.16-0.95], p = 0.038). Adjusting for age, cirrhosis was associated with a higher mortality (5.96 [1.05-33.57]; p = 0.043). Adjusting for age, gender, and concomitant antiretroviral treatment, cirrhosis was also associated with a prolonged hospitalization (> 7 days: 9.30 [1.84-46.82]; p = 0.007). CONCLUSION: The diagnosis of CABP can be difficult in cirrhotic HIV-positive patients because clinical presentation is milder. However, CABP needs to be promptly recognized because mortality is higher in these patients.

Screening-detected breast carcinoma in a patient with Cowden syndrome.

Cowden syndrome is a hereditary genetic disease whose incidence is still not precisely defined; it is due to a germline mutation in the PTEN gene. We reported a case of breast tumor caused by a PTEN gene mutation, which was detected within a National Screening Program; the diagnosis of Cowden syndrome was made on the basis of patient's particular clinical history. The identification of new genetic mutations has allowed clarification of some of the mechanisms that increase the risk of developing some types of tumors. Furthermore, new kind of mutations recently reported in the literature raise questions about their prognostic significance and how their carriers can be better screened, counseled and managed. These problematic issues will be encountered with increasing frequency in the near future, since many other more mutations are sure to be discovered. The PTEN gene mutation has been implicated in various human tumors, mainly in the breast and the thyroid gland. In the course of a screening program, the early identification of patients affected by a genetic mutation, which is rare, improves the definition of the prognosis and the therapeutic options.

Pilot dose-finding trial on interferon alpha in combination with ribavirin for the treatment of chronic hepatitis C in patients not responding to interferon alone.

BACKGROUND: Effectiveness of combination therapy with standard interferon alpha doses and ribavirin is far from being demonstrated in patients with hepatitis C non responders to interferon alpha monotherapy. Recent kinetic studies revealed that these doses may be suboptimal. AIMS: To find the criteria for optimisation of the interferon dose, to be used in combination with ribavirin in patients with hepatitis C non responders to interferon alpha monotherapy. PATIENTS: Sixty-three patients enrolled in a pilot controlled trial were treated for 6 months with ribavirin ([1000-1200 mg daily) and were randomised to concurrently receive interferon alpha 2b for 6 months at: 3 Million Units thrice weekly [group A (21 patients)], 5 MU thrice weekly [group B (21 patients)] and 5 million units daily [group C (21 patients)]. RESULTS: A sustained virological response was observed in: 1 patient from group A (5%), 2 patients from group B (9%) and 8 patients from group C (38%; p=0.02 vs group A; p=0.03 vs group B). Side-effects were not significantly different between the 3 groups. Multivariate analysis showed that infection by hepatitis C virus genotypes 2 or 3 and interferon alpha dosage of 5 million units daily were independent predictors of sustained response. CONCLUSIONS: These results suggest that higher interferon doses administered daily in combination with ribavirin could be more effective in those patients with hepatitis C who had not responded to interferon alone.

Diagnostic and prognostic indices in primary open angle glaucoma: a color Doppler study.

The authors compute a diagnostic (Di) and a prognostic (Pi) index in primary open angle glaucoma. Four groups of patients were studied. Group A consisted of subjects under 50 years of age, group B of subjects over 50 years of age, group C of patients with normal tension glaucoma and group D with high tension glaucoma. All patients underwent color doppler imaging of the ophthalmic, posterior ciliary and choroid arteries. The Di of the choroid vessels were 0.967 +/- 0.011 (gp. A), 1.112 +/- 0.010 (gp. B), 1.506 +/- 0.008 (gp. C) and 2.891 +/- 0.083 (gp. D). The Pi of the posterior ciliary arteries were 22.700 +/- 1.160 (gp. A), 20.000 +/- 0.943 (gp. B), 15.100 +/- 0.568 (gp. C) and 12.100 +/- 0.083 (gp. D). Confirmation of these data might validate them as a tool for preventing the evolution of glaucomatous optic neuropathy.

Zidovudine prophylaxis after accidental exposure to HIV: the Italian experience. The Italian Study Group on Occupational Risk of HIV Infection.

OBJECTIVES: To evaluate the use of zidovudine prophylaxis in HIV-exposed health-care workers (HCW) in Italy and to determine its short-term toxicity. DESIGN: Longitudinal, open study with retrospective and prospective collection of data. SETTING: All Italian clinical centres that care for HIV-infected patients and are licensed by the Ministry of Health to dispense zidovudine and 30 hospitals participating in the Italian Multicentre Study on Occupational Risk of HIV Infection. STUDY POPULATION: HCW and other individuals who accepted zidovudine prophylaxis after accidental exposure to HIV. RESULTS: Data were collected for 224 HIV-exposed individuals until 30 June 1991. An increase in zidovudine prophylaxis was observed. All but 10 subjects received 1000-1250 mg zidovudine per day. Anaemia (five cases), neutropenia (one case) and an increase in serum alanine aminotransferase levels (two cases) were the only haematochemical side-effects observed; none of the subjects ceased prophylaxis because of side-effects. More than 50% of subjects had constitutional reactions; as a result, prophylaxis was stopped by 29 patients. These adverse effects began within 10 days of prophylaxis; all resolved after prophylaxis was stopped. No HIV-antibody seroconversions were observed after a mean follow-up of 8 months. CONCLUSIONS: Zidovudine prophylaxis has become a feature of the management of occupational exposures to HIV in health-care settings; short-term toxicity is mild, dose-related and reversible. Further studies are needed to assess the risk of long-term sequelae.

Choroidal thickness in primary glaucoma.

A and B scan echography does not allow to measure separately the thickness of the three ocular layers, retina, choroid and sclera. This, however, is possible by radiofrequency signals. 48 eyes of normal subjects and 21 eyes of patient suffering from chronic glaucoma with ocular hypertension from 30 to 45 mm Hg were examined. The thickness of the retina and sclera was equal in the two groups, whereas the thickness of the choroid in the glaucomatous eyes showed an increase of 20% as compared with normal eyes.

A case of cryptococcal meningoencephalitis and focal cerebral vasculitis with transient immunodeficiency.

The AA. report a case of CNS cryptococcosis with vasculopathic complications in a woman in perfect physical conditions. The patient was admitted to hospital after complaining for 20 days of fever, headache and rachialgia. CSF examination revealed hypoglicorrachia (18 mg %), cells 440 mmc (polymorphonuclear leukocytes 90%), brain CT scan negative. During antimycobacterial treatment right hemiparesis appeared; brain CT: hypodense lesion in the posterior brachium of the left inner capsule; at its base the lesion showed a hypodense streak coherent with thromboembolic damage or deep vasculitis. OKT4 lymphocytes were 6% (absolute number: 70). The antimycotic treatment, following the positive reaction of the CSF culture to Cryptococcus Neoformans, entirely cured the hemiparesis and normalized the CSF while OKT4 lymphocytes rapidly grew.

HIV1-Ag in cerebrospinal fluid during AIDS.

HIV infection may display neurological symptoms at any stage; the virus can be isolated from the cerebrospinal fluid (CSF) of both symptomatic and asymptomatic patients and of two third of patients with AIDS. This study sought to determine the sensitivity of HIV1-Ag in the CSF of an HIV-Ab positive population to evaluate its diagnostic and/or prognostic significance. CSF HIV1-Ag was dosed in 48 patients: 9 patients belonged to the III CDC group, 2 to group IVA, 1 to IVB and 36 to IVC1. In the last group, 14 patients had not opportunistic infections of the CNS. The tests proved positive in: 1 IVB patient and 16 IVC patients with focal lesions of the CNS or cerebral atrophy; HIV1-Ag was present in the CSF of 63% of patients displaying neurologic symptoms and it reached 84% in patients with diffuse CNS pathology.

Compensation of random eye motion in television ophthalmoscopy: preliminary results.

Involuntary eye movements make the observation of the ocular fundus on a TV monitor fatiguing for the physician, not to mention the practical impossibility of measuring dynamic phenomena such as the venous pulse observed in a sensible percentage of patients. It is therefore necessary to measure and compensate, for display and analysis, the displacement between each image in the video sequence and a reference one. This paper reports the results of a preliminary set of registration experiments, carried out on low quality photographs of the ocular fundus obtained without contrast medium. The results confirm the robustness of the chosen approach, phase correlation. The effects of choices such as computer word length or raw-data windowing on system performance are also analyzed.

Effect of kainic acid, glutamate, and aspartate on CO2 production by goldfish tectal slices.

For a study of the excitatory effect of kainate, glutamate, and aspartate in the goldfish optic tectum, these substances were tested on the production of CO2 from radioactive glucose in tectal slices incubated in Krebs-Ringer medium for fish. Kainate increased the rate of CO2 production for up to 30 min in a dose-related manner, the effect being maximum at 0.1 mM concentration and decreasing at higher doses. The effect was blocked by ouabain (1 mM) as well as by the substitution of choline for Na+ in the incubation medium. Glutamate and aspartate exerted a less pronounced excitatory effect on CO2 production at higher concentration than kainate. This effect was also abolished by ouabain. Glutamate, added to the medium at a concentration at least 100-fold higher than kainate, partially reversed the increase in CO2 production induced by kainic acid. No similar effect was noticed for aspartate. The supposed glutamate antagonists glutamic acid diethylester (1 mM) and proline (5 mM) did not affect the excitatory action of kainic acid or exert an antagonistic effect towards glutamate. At higher concentration (10 mM) glutamic acid diethylester increased CO2 production, an effect that was, however, ouabain insensitive. Methyltetrahydrofolic acid (1 mM), a substance reported to compete for the kainate receptor, did not inhibit the effect of kainic acid or increase CO2 production.

Kainic acid neurotoxicity does not depend on intact retinal input in the goldfish optic tectum.

Kainic acid neurotoxicity has been studied in the optic tectum of the goldfish 4 weeks after eye enucleation. The effect of drug treatment has been tested with respect to both neurochemical and morphological parameters. The neurotransmitter-related enzymes, choline acetyltransferase, acetylcholinesterase and glutamate decarboxylase, show about 50% decrease in the deafferented tectum 6 days after kainic acid administration. Relevant morphological alterations of the tectal structure can also be noticed at the same stage. The neurotoxic effects of kainic acid in the deafferented optic tectum are therefore quite similar to the effects of previously noticed for the intact optic tectum of normal fish. Control experiments on the effect of optic nerve degeneration by itself on the levels of the neurotransmitter-related enzymes in the optic tectum, have shown no significant decrease in glutamate decarboxylase, a slight decrease in acetylcholinesterase and a more marked drop in choline acetyltransferase. The findings are discussed with reference to some of the hypotheses advanced in order to explain kainic acid neurotoxicity. It is proposed that the neurotoxic effect of kainic acid after removal of specific excitatory afferents, may vary in different nervous centers depending on differences of the remaining extrinsic connections and of the intrinsic neural circuits.

Evidence of intrinsic cholinergic circuits in the optic tectum of teleosts.

Choline acetyltransferase (CAT) was assayed in the optic tectum of 4 teleost species with different visual powers. The results showed a close relationship between the enzyme levels in the optic tectum and the development of the visual system. In the more visual species, the trout, CAT activity in the optic tectum was about 30-fold higher than in the catfish, whose visual system is much less developed. Two species with intermediate development of the visual system, the goldfish and the tench, showed intermediate levels of CAT activity. Kainic acid treatment caused a significant decrease in both CAT and acetylcholinesterase (AChE) in the goldfish optic tectum. Concomitant histological examination showed, among other effects, the disappearance of most neurons belonging to the pyramidal and fusiform type in the striatum fibrosum and griseum superficiale of the tectum. The comparative and experimental data therefore suggest that the relationship between cholinergic mechanisms and the visual function is, to a significant extent, connected with the presence of intrinsic cholinergic circuits in the optic tectum. The relevance of these findings, also in relation to the problem of the identification of the retino-tectal transmitter, is discussed.

Ocular hypertension in primary glaucoma: a new hypothesis.

Some considerations of the vascular events occurring the uvea during the course of glaucoma are reported and a mathematical model is adopted to clarify the interdependence between intraocular pressure, rate of blood flow, blood pressure gradient, and the number of unobstructed capillary vessels in the uveal membrane. By means of this mathematical model the physiopathological vascular cause of the rise in intraocular pressure is confirmed (also independently of an obstacle to aqueous outflow), and the clinical implications in relation to visual sensory impairment are emphasized.