Large particle hyaluronic acid for the treatment of facial lipoatrophy in HIV-positive patients: 3-year follow-up study.

OBJECTIVES: Facial lipoatrophy can be a stigmatizing side effect of antiretroviral (AVR) treatment for HIV-infected patients. We sought to evaluate the long-term efficacy and safety of a new formulation of hyaluronic acid that can be injected in larger amounts and into deeper skin layers during 3 years of follow-up. METHODS: Twenty patients received injections of Restylane SubQ(). Refill treatment was offered at 12 and 24 months. Treatment effects were evaluated using ultrasound, the Global Aesthetic Improvement Scale, visual analogue scale (VAS) and the Rosenberg self-esteem scale. RESULTS: Seventeen patients remained at 36 months. Mean (+/- standard deviation) total cutaneous thickness increased from 6 +/- 1 mm at baseline to 12 +/- 1 mm (P<0.001) at 36 months. Response rate (total cutaneous thickness >10 mm) was 70%. Fifteen patients classified their facial appearance as very much or moderately improved. VAS increased from 39 +/- 25 to 70 +/- 20 (P<0.05) and higher self-esteem scores were reported. Local swelling and tenderness after treatment was common. Persistent papules found in several patients after treatment were removed effectively with hyaluronidase injections. Three patients, treated only at baseline, still had higher total cutaneous thickness scores at 36 months. CONCLUSIONS: Our results indicate that a large particle hyaluronic acid formulation is a durable and well-tolerated dermal filler for treating HIV-positive patients with facial lipoatrophy.

Crohn's disease evaluated with magnetic resonance enteroclysis: diagnostic performance of experienced and inexperienced readers before and after training.

BACKGROUND: Magnetic resonance enteroclysis (MRE) is suggested to become the preferred radiological method in small-bowel Crohn's disease (CD). However, the performance of inexperienced readers may influence the diagnostic value of the method and has not been previously investigated. PURPOSE: To compare readings of MRE in small-bowel CD performed by experienced and inexperienced readers before and after training. MATERIAL AND METHODS: One experienced radiologist (observer 1) and two trainees (observers 2 and 3) reviewed 60 MRE examinations. A second reading was performed after training. Bowel wall thickness (BWT), ulcers (BWU), stenosis (BWS), fistulas (FIS), and abscesses (ABS) were evaluated. A reference standard based on clinical records was established. RESULTS: BWT in the terminal ileum was evaluated with high diagnostic performance (sensitivity: observer 1, 83%; observer 2, 72%; observer 3, 78%). Only BWU was diagnosed with a higher sensitivity by observer 1 (78% vs. 33% and 39%, respectively; P=0.02). False-positive findings for BWT in the jejunum (observer 2: 7; observer 3: 4) and fistulas and abscesses (observer 2: 11/5; observer 3: 5/4) were made by the trainees. Interobserver agreement in the jejunum was poor (observer 1/observer 2: kappa=0.23; observer 1/observer 3: kappa=-0.03) and in the ileum good (observer 1/observer 2: kappa=0.78; observer 1/observer 3: kappa=0.73). After training, evaluation of BWU (observer 2: 56%, P=0.22; observer 3: 44%, P=0.03), BWT (observer 2: 2; observer 3: 2), and interobserver agreement in the jejunum improved (observer 1/observer 2: kappa=0.66; observer 1/observer 3: kappa=0.66). However, the number of diagnosed fistulas and abscesses remained high. CONCLUSION: Before training, most findings of Crohn's disease in the terminal ileum were evaluated with high diagnostic performance by all readers. However, the inexperienced readers evaluated BWU with a low sensitivity and overestimated the number of FIS, number of ABS, and increased BWT in the jejunum. After training, evaluation by inexperienced readers of BWU and increased BWT in the jejunum improved.

White matter lesion severity is associated with reduced cognitive performances in patients with normal CSF Abeta42 levels.

OBJECTIVE: To identify possible associations between white matter lesions (WML) and cognition in patients with memory complaints, stratified in groups with normal and low cerebrospinal fluid (CSF) Abeta42 values. MATERIAL AND METHODS: 215 consecutive patients with subjective memory complaints were retrospectively included. Patients were stratified into two groups with normal (n = 127) or low (n = 88) CSF Abeta42 levels (cut-off is 450 ng/l). Cognitive scores from the Mini-Mental State Examination (MMSE) and the Neurobehavioral Cognitive Status Examination (Cognistat) were used as continuous dependent variables in linear regression. WML load was used as a continuous independent variable and was scored with a visual rating scale. The regression model was corrected for possible confounding factors. RESULTS: WML were significantly associated with MMSE and all Cognistat subscores except language (repetition and naming) and attention in patients with normal CSF Abeta42 levels. No significant associations were observed in patients with low CSF Abeta42. CONCLUSIONS: WML were associated with affection of multiple cognitive domains, including delayed recall and executive functions, in patients with normal CSF Abeta42 levels. The lack of such associations for patients with low CSF Abeta42 (i.e. with evidence for amyloid deposition), suggests that amyloid pathology may obscure cognitive effects of WML.

Hyaluronic acid treatment of facial fat atrophy in HIV-positive patients.

OBJECTIVES: Facial lipoatrophy can be devastating for HIV-infected patients, with negative effects on self-esteem. In this study, we treated facial fat atrophy in the nasogenian area with hyaluronic acid (Restylane SubQ; Q-Med AB, Uppsala, Sweden). METHODS: Twenty patients were included in the study. Treatment effects were evaluated at baseline, and at weeks 6, 24 and 52 using ultrasound, the Global Aesthetic Improvement Scale, the Visual Analogue Scale and the Rosenberg Self-Esteem Scale. RESULTS: Mean (+/-standard deviation) total cutaneous thickness increased from 6+/-1 mm at baseline to 15+/-3 mm at week 6 (P<0.001), and declined to 10+/-2 mm at week 52 (P<0.001 vs baseline). The response rate (total cutaneous thickness >10 mm) was 100% at week 6, 85% at week 24 and 60% at week 52. At week 6, all of the patients classified their facial appearance as very much improved or moderately improved. They also reported increased satisfaction with their facial appearance and had higher self-esteem scores. At week 52, 15 of 19 patients still classified their facial appearance as very much improved or moderately improved, although the mean total cutaneous thickness had gradually declined. CONCLUSIONS: Our results indicate that Restylane SubQ is a useful and well-tolerated dermal filler for treating HIV-positive patients with facial lipoatrophy.

Magnetic resonance enteroclysis in the diagnosis of small-intestinal Crohn's disease: diagnostic accuracy and inter- and intra-observer agreement.

PURPOSE: To evaluate the diagnostic accuracy and inter- and intra-observer agreement of magnetic resonance enteroclysis (MRE) in patients with or without Crohn's disease of the small intestine. MATERIAL AND METHODS: 60 consecutive patients with or without Crohn's disease examined with MRE were included. Two observers independently reviewed the MRE examinations, searching for 12 pathological signs. The reference standard was ileoscopy or surgery of the terminal ileum performed in 41 patients. RESULTS: Crohn's disease of the small intestine was found in 24 (40%) patients. MRE findings of increased intestinal wall thickness, intestinal wall enhancement, intestinal wall ulcer, and inflammatory activity of the terminal ileum showed high sensitivity, specificity, and positive and negative predictive values. Intestinal stenosis had sensitivities ranging from 43% to 100%, depending on the cut-off value. Inter- and intra-observer agreement was good or excellent for most pathological signs. However, observer agreement of intestinal wall edema was only fair and moderate. CONCLUSION: MRE evaluated Crohn's disease with a high diagnostic accuracy in the terminal ileum. Most MRE variables were evaluated with good or excellent observer agreement, indicating that the method was highly reproducible. Our study supports the notion that MRE is an appropriate method for diagnosing Crohn's disease.

Associations between white matter lesions, cerebrovascular risk factors, and low CSF Abeta42.

OBJECTIVE: To analyze a putative relationship between white matter lesions (WMLs), risk factors for WMLs, and Alzheimer disease (AD) as measured with the surrogate marker CSF Abeta42. METHODS: The authors analyzed effects of acquired risk factors for cerebrovascular disease and WMLs on AD as measured with an intermediate marker, CSF Abeta42. A total of 127 consecutive patients with subjective memory impairment (mean age 66 years; 57 women) investigated at a university-based memory clinic had brain MRI scans. WMLs were rated on a 12-point scale with a semiquantitative procedure. They used path analysis with established and possible risk factors for WMLs and for reduced CSF Abeta42 (age, hypertension, hyperhomocysteinemia, hypercholesterolemia, APOE-epsilon4) as variables. RESULTS: The WML score was 1.5 points higher (p < 0.05) in hypertensive than in nonhypertensive patients and 1.9 points higher (p < 0.05) in patients with hyperhomocysteinemia than in those with normal homocysteine levels. Hypercholesterolemia increased the probability of low CSF Abeta42 levels by 0.2 (p < 0.05). For each point increase in WML score, the probability of low CSF Abeta42 levels increased by 0.03 (p < 0.05). APOE-epsilon4 was associated with reduced CSF Abeta42 (p < 0.01). CONCLUSION: Both hypercholesterolemia and white matter lesions may contribute to low CSF Abeta42 by independent mechanisms.