Anorectal Crohn's disease

A group of 86 patients with anorectal Crohn's disease were followed up from ten to 40 years to determine the course of the disease and the number of patients who later required proctectomy. The overall cumulative probability of avoiding proctectomy was 91.6 percent at ten years and 82.5 percent at 20 years. Resection of all proximal Crohn's disease did not ameliorate the anorectal disease, except in patients who had all proximal disease removed and had no recurrence. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, May 5 to 10, 1985.     

The role of bronchoscopy in the diagnosis and treatment of pulmonary disease in HIV-infected patients

Background: Pulmonary disease is the most common reason for presentation and the major cause of death in HIV-infected patients. There has been an evolution in the optimal approach to the investigation of a pulmonary infiltrate in HIV-infected patients since the introduction of induced sputum for the diagnosis of Pneumocystis carinii pneumonia (PCP). Aims: To evaluate the usefulness of flexible fibreoptic bronchoscopy (FFB), bronchoalveolar lavage (BAL), transbronchial biopsy (TBB) and bronchial brushings (BB) in the diagnosis of pulmonary disease in HIV-infected patients and to examine the effect of FFB on changes in therapy and survival. Methods: The histories of all HIV-infected patients referred to Fairfield Hospital for FFB between January 1990 and June 1993 were examined retrospectively. Results: Forty-two FFB were performed on 41 patients (40 male and one female). Definitive diagnoses made at FFB included Kaposi's sarcoma (KS) (n= 9), invasive aspergillosis (n= 5), PCP (n= 4), Mycobacterium avium complex (MAC) pneumonia (n= 2), cytomegalovirus (CMV) pneumonia (n= 1), Cryptococcus neoformans pneumonia (n= 1), microsporidium (n= 1) and Pseudomonas aeruginosa pneumonia (n= 1). TBB and BB did not provide a diagnosis for diseases not seen macro-scopically at FFB or diagnosed by BAL. FFB findings altered diagnosis in 21/42 (50%) presentations and changed therapy in 26/42 (62%) cases. Conclusions: FFB together with BAL altered the working diagnosis and changed therapy in a significant number of patients. TBB and BB should not be routinely performed in all patients as these procedures are of limited value in this setting.     

Malignancies in HIV-infected Thai patients

Of 1416 HIV-infected patients seen at Ramathibodi Hospital over a 5-year period (1999-2003), 42 were diagnosed with malignancies, giving a prevalence of 3%. Twenty-one of these patients (50%) were men and their mean age was 40.8 years. The median CD4 cell count was 235 cells/muL. AIDS-related malignancies were found in 26 patients (62%). The most common AIDS-related malignancies were non-Hodgkin's lymphoma (NHL) (33%), cervical cancer (21%) and Kaposi's sarcoma (KS) (5%). Breast cancer was the most common non-AIDS-related malignancy (10%). Eleven patients (26%) died. The 75% survival time of patients who received treatment for their malignancy was longer than that of patients who received no treatment (18.3 vs 1.2 months; P<0.01).     

Anorectal disease in neutropenic leukemic patients

PURPOSE: This study was designed to evaluate the spectrum, clinical presentation, management, and outcome of anorectal disease in neutropenic leukemic patients and to compare operative and nonoperative management in neutropenic leukemic patients. METHODS: A retrospective review of hospital records was performed. RESULTS: One hundred fifty-one of 2,618 (5.8 percent) patients hospitalized with leukemia had concomitant symptomatic anorectal disease. Data from 81 patients were available for analysis. Fifty-two (64 percent) were treated nonoperatively and 29 (36 percent) underwent operative treatment. Fifty-seven (70.4 percent) had absolute neutrophil counts <1,000/ mm ³,and 54 (66.7 percent) were severely neutropenic (absolute neutrophil count <500/mm ³).Management and outcomes of 54 severely neutropenic patients were analyzed. In 20 patients who underwent surgery there were 4 deaths (20 percent) and 4 recurrences (20 percent), whereas in 34 patients managed nonoperatively there were 6 deaths (18 percent) and 4 recurrences (12 percent) (P >0.05). CONCLUSIONS: Symptomatic anorectal disease afflicted 5.8 percent of hospitalized leukemic patients. In these patients, anorectal sepsis was a major source of mortality. Our data suggest that anorectal abscesses in neutropenic leukemic patients may be safely drained. Because we did not observe excessive morbidity or mortality (20 percent vs. 18 percent) in the operated neutropenic leukemics as compared with the nonoperated patients, selected neutropenic leukemic patients should not be denied anorectal surgery when otherwise indicated.Read at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.Dr. Guillem is recipient of a Career Development Award from the American Cancer Society and a Grant from the Richard Molin Foundation.     

Anorectal sepsis as a presentation of occult rectal and systemic disease

Between 1980 and 1982, 233 patients were treated for anorectal sepsis in three hospitals. The incidence of underlying disease associated with perianal sepsis and the results of surgical treatment were assessed retrospectively. Of the 233 patients who had perianal sepsis, 136 (58.4 percent) had perianal abscesses, while a further 12 (5.1 percent) had associated fistulas. Ischiorectal abscesses, while a further 12 (5.1 percent) had and a further two (0.9 percent) had fistulas. Four (1.8 percent) patients were found to have intersphincteric abscesses. One hundred and nine (46.8 percent) had examination under anesthesia or definitive procedures, while the remaining 124 (53.2 percent) had incision and drainage alone. A second procedure was required by 55 (23.6 percent) patients, 40 (32 percent) in the group who had incision and drainage patients, 40 (32 percent) in the group who had incision and drainage only and 15 (14 percent) of those having initial examination under anesthesia (P<.001). Twenty-seven (11.6 percent) patients had occult disease. Twelve patients (5.1 percent) had systemic disease (six diabetic, three nongastrointestinal neoplasia, two inflammatory, and 1 hematologic), while of the 109 patients who had examinations under anesthesia, 15 (6.4 percent) had associated colorectal pathology (four neoplasia, 11 inflammatory). It is important that patients with anorectal sepsis have complete medical and surgical assessments at the time of their first admission.     

Predicting short-term disease progression among HIV-infected patients in Asia and the Pacific region: preliminary results from the TREAT Asia HIV Observational Database (TAHOD)

OBJECTIVES: HIV disease progression has been well documented in Western populations. This study aimed to estimate the short-term risk of AIDS and death from the TREAT Asia HIV Observational Database (TAHOD), a prospective, multicentre cohort study in Asia and the Pacific region. METHODS: Prospective data were analysed to estimate short-term disease progression. Endpoints were defined as the time from study entry to diagnosis with AIDS or death. Antiretroviral treatment was fitted as a time-dependent variable. Predictors of disease progression were assessed using Cox proportional hazards models, and prognostic models were developed using Weibull models. RESULTS: A total of 1260 patients with prospective follow-up data contributed 477 person-years of follow-up, during which 18 patients died and 34 were diagnosed with AIDS, a combined rate of 10.1 per 100 person-years. Compared with patients receiving antiretroviral treatment, patients not on treatment had a higher rate of disease progression (17.6 vs. 8.1 per 100 person-years, respectively). Baseline CD4 count was the strongest predictor of disease progression. Prognostic models, using either a baseline CD4 count as the sole marker or markers including baseline haemoglobin, AIDS-related symptoms and previous or current antiretroviral treatment, were successful at identifying patients at high risk of short-term disease progression. CONCLUSIONS: Similar to the situation in Western countries, baseline CD4 count was the strongest predictor of short-term disease progression. Prognostic models based on readily available clinical data and haemoglobin level should be useful in estimating short-term clinical risk in HIV-infected patients in Asia and the Pacific region.     

Preventive medicine for HIV-infected patients

Objective:To analyze the policies of isoniazid prophylaxis for human immunodeficiency virus (HIV)-infected tuberculin reactors and for HIV-infected anergic patients with unknown tuberculin status. Methods:Transition-state model of clinical immune deterioration of HIV-infection over ten years, review of published data, and a survey of AIDS experts. Outcome measures are the numbers of tuberculosis cases and deaths prevented and isoniazid toxicity cases and deaths occurring with prophylaxis. Patients:Hypothetical cohorts of HIV-infected 40-year-olds. Results:Because the tuberculosis activation rate is so high in HIV-infected patients, the benefits of prophylaxis far outweigh the risks of isoniazid toxicity for tuberculin reactors with HIV infection at any stage of immune function: 1,469–2,868 tuberculosis cases and 170–274 deaths are prevented per 10,000 cohort over ten years, depending upon the cohort’s initial immune state. The benefits of prophylaxis outweigh the risks of isoniazid toxicity for anergic HIV-infected patients if they come from a community with a 2% to 3% or greater prevalence of Mycobacterium tuberculosisinfection. Conclusions:Isoniazid prophylaxis is a reasonable prevention measure for HIV-infected tuberculin reactors and for many HIV-infected anergic patients. Received from the Departments of Medicine, Community Medicine, and Biomathematical Sciences, the AIDS Center, and the Clinical Trials Unit, Mount Sinai School of Medicine, New York, New York. Presented in part at the 14th annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1–3, 1991. Supported in part by the following grants: 1/RO1 MH45686 from the National Institute of Mental Health, and UO1 AI27667 and UO1 AI27554 from the National Institute of Allergy and Infectious Diseases.     

Anorectal Pathology in HIV/AIDS-Infected Patients Has Not Been Impacted by Highly Active Antiretroviral Therapy

PURPOSE: The aim of this study was to determine if the prevalence and distribution of anorectal pathology in HIV-infected patients treated by colorectal surgeons have changed after the introduction of highly active antiretroviral therapy.METHODS: The Los Angeles County–University of Southern California HIV Clinic is solely dedicated to the care of HIV patients. A colorectal clinic was established within this environment in 1991 and has served as the exclusive provider for the care of anorectal pathology in these patients. A prospective database of patients treated at this clinic was reviewed for two 18-month periods. The first group (early period) was composed of patients treated between January 1994 through June 1995, before the institution of more effective antiretroviral therapy. The second group (later period) consisted of patients treated between January 2001 through June 2002, after the introduction of highly active antiretroviral therapy. Data were tabulated for HIV-related anorectal pathologies, such as anal ulcer and anogenital condyloma, and non-HIV-related pathologies, including fissure, fistula in ano, hemorrhoids, perianal abscess, and other pathologies, for each of the two time periodsRESULTS: A total of 117 individual patients with anorectal pathology were treated in the early period and 109 received care in the later period, of which 107 were able to be evaluated. The pathology was distributed as follows for the early vs. late periods: 33 vs. 33 percent for ulcer, 30 vs. 34 percent for condyloma, 9 vs. 4 percent for fissure, 6 vs. 6 percent for fistula, 4 vs. 5 percent for hemorrhoids, 3 vs. 3 percent for abscess, and 15 vs. 16 percent for all other anorectal pathology. There was no statistically significant difference in any of these groups.CONCLUSION: The prevalence and distribution of both HIV-related and non-HIV-related anorectal pathology seen in our HIV patients have not been altered by the introduction of highly active antiretroviral therapy.Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.This report was presented at the XIV International Conference on AIDS, Barcelona, July 7 to 12, 2002.Reprints are not available.     

Colorectal cancer in HIV-infected patients: a case control study

Background Data on colorectal cancer (CRC) in HIV-positive patients are limited. The objective of this study was to investigate the incidence, presentation, and outcome of CRC in HIV patients. Materials and methods Clinical data on patients diagnosed with CRC and concurrent HIV/AIDS infection between 1994 and 2003 were retrieved from the institutional records. Each identified patient was randomly matched with two HIV-negative CRC patients based on age, sex, race, and TNM stage at cancer diagnosis. Presentation, treatment toxicities, recurrence, and overall survival rates were assessed. Data were further compared with those of the published international Surveillance Epidemiology and End Results (SEER) data. Results Out of 3,951 CRC patients, 12 HIV CRC patients (0.3%) were identified. Median age at cancer diagnosis was 41 years (29–52), revealing a 3:1 ratio between patients younger and older then 50 years, compared to a 1:33 ratio in the general population. Compared to 57% in the general population, 90% of the patients had advanced stages (III–IV) at diagnosis. The median follow-up time for both cases and controls was 30 months (6–65). HIV-positive patients had a shorter disease-free survival than the controls. No difference in overall survival was demonstrated, however survival was significantly reduced in the HIV-positive patients when only patients who were initially disease-free were compared. Adjuvant therapy was well-tolerated in all patients without chemotherapy-related deaths. Conclusion HIV-positive CRC patients tend to have an early and more aggressive presentation with less favorable outcome. Further epidemiology studies to refute or accept our observations may suggest a reduced threshold for screening for CRC in HIV-positive patients.     

Schistocytosis and a thrombotic microangiopathy-like syndrome in hospitalized HIV-infected patients

Approximately 150 human immunodeficiency virus (HIV)-infected patients with a thrombotic microangiopathy (TMA)-like syndrome have been reported in the literature since the early 1980s. The prevalence of a TMA-like syndrome in our hospitalized patients was determined to discern whether it is a more common occurrence than previously recognized and, if possible, to delineate risk factors for its occurrence. A total of 350 patients admitted consecutively to the Johns Hopkins Hospital HIV inpatient service were assessed from May 1, 1996 through February 1, 1997. These patients were evaluated for the presence of anemia, thrombocytopenia, fragmented erythrocytes on peripheral blood smear (schistocytosis), renal dysfunction, neurologic dysfunction, and fever. The association of a TMA-like syndrome with demographic and clinical factors was analyzed. Schistocytosis was present in 24% of the patients and a TMA-like syndrome (anemia, thrombocytopenia, schistocytosis + renal dysfunction or neurologic dysfunction, and fever) was present in 7% of the patients. The patients who had a TMA-like syndrome were more likely to have a low CD4 lymphocyte count or CD4 percentage, Centers for Disease Control and Prevention stage C disease, and have bacterial sepsis. Age, race, HIV risk group, other diagnoses, and prescribed drugs were not associated. Patients were more likely to die if they had a TMA-like syndrome, independently of level of immunosuppression. Schistocytosis and a TMA-like syndrome are relatively common in hospitalized HIV-infected patients. This syndrome may contribute to mortality and morbidity, particularly in patients with more advanced disease. Am. J. Hematol. 60:116–120, 1999. © 1999 Wiley-Liss, Inc.     

Pulmonary complications of immune reconstitution inflammatory syndromes in HIV-infected patients

Immune reconstitution inflammatory syndrome (IRIS) describes a paradoxical worsening of clinical status related to recovery of the immune system, as can occur after the initiation of highly active antiretroviral therapy (HAART) in HIV-infected patients. Most commonly, IRIS results from opportunistic infections that can unmask or develop paradoxical worsening following HAART. Cancers, autoimmune conditions and sarcoidosis have also been associated with IRIS. Pulmonary complications may be frequently encountered. This article reviews the types and clinical presentation of IRIS, with a focus on the pulmonary manifestations. Management and outcome of IRIS are considered.     

Prevalence and prognostic significance of ECG abnormalities in HIV-infected patients: results from the Strategies for Management of Antiretroviral Therapy study

Background

It remains debated whether to include resting electrocardiogram (ECG) in the routine care of human immunodeficiency virus (HIV)–infected patients.

Methods

This analysis included 4518 HIV-infected patients (28% women and 29% blacks) from the Strategies for Management of Antiretroviral Therapy study, a clinical trial aimed to compare 2 HIV treatment strategies. ECG abnormalities were classified using the Minnesota Code. Cox proportional hazards analysis was used to examine the association between baseline ECG abnormalities and incident cardiovascular disease (CVD).

Results

More than half of the participants (n = 2325, or 51.5%) had either minor or major ECG abnormalities. Minor ECG abnormalities (48.6%) were more common than major ECG abnormalities (7.7%). During a median follow-up of 28.7 months, 155 participants (3.4%) developed incident CVD. After adjusting for the study-treatment arms, the presence of major, minor, and either minor or major ECG abnormalities was significantly predictive of incident CVD (hazard ratio [95% confidence interval]: 2.76 [1.74-4.39], P < .001; 1.58 [1.14-2.20], P = .006; 1.57 [1.14-2.18], P = .006, respectively). However, after adjusting for demographics, CVD risk factors, and HIV characteristics (full model), presence of major ECG abnormalities were still significantly predictive of CVD (1.83 [1.12-2.97], P = .015) but not minor or major abnormalities taken together (1.26 [0.89-1.79], P = .18; 1.25 [0.89-1.76], P = .20, respectively). Individual ECG abnormalities that significantly predicted CVD in the fully adjusted model included major isolated ST-T abnormalities, major prolongation of QT interval, minor isolated ST-T, and minor isolated Q-QS abnormalities.

Conclusion

Nearly 1 in 2 of the HIV-infected patients in our study had ECG abnormalities; 1 in 13 had major ECG abnormalities. Presence of ECG abnormalities, especially major ECG abnormalities, was independently predictive of incident CVD. These results suggest that the ECG could provide a convenient risk-screening tool in HIV-infected patients.     

Evaluation of different staging systems for Kaposi's sarcoma in HIV-infected patients

Summary The records of 49 consecutive AIDS patients with Kaposi's sarcoma were analysed retrospectively to assess the prognostic value of the four staging systems proposed for epidemic Kaposi's sarcoma. The classifications by Krigel and Mitsuyasu do not describe exactly the characteristics of the disease, and do not give enough information on survival. Our study confirms that CD4⁺ cell depletion, systemic symptoms and opportunistic infections at diagnosis are the major prognostic factors and influence survival to a great extent, as shown by Krown and Chachoua.Abbreviations EKS epidemic Kaposi's sarcoma - OI opportunistic infections - SS systemic symptoms     

Kaposi's sarcoma in HIV-infected patients: treatment options

Summary Kaposi's sarcoma (KS) is the most prevalent AIDS-associated tumour, occurring in 20–30% of HIV-1-infected individuals in the early 1980s. The introduction of highly active antiretroviral therapy (HAART) has dramatically reduced the incidence of the disease and might therefore support the concept of 'opportunistic malignancies' requiring immune impairments to occur. The relationship between the immune system and the epidemiology of this virus-induced tumour is of importance in order to identify new therapeutic approaches for treating or preventing its occurrence. As a model of impaired angiogenesis, therapeutic options for treating AIDS patients with KS should therefore target cell division, anti-angiogenic processes, immune modulators, cytokines and potentially antiviral drugs.     

The prevalence and risk of immune restoration disease in HIV-infected patients treated with highly active antiretroviral therapy

BACKGROUND: It is becoming increasingly clear that, during successful highly active antiretroviral therapy (HAART), a proportion of treated patients develop opportunistic infections (OIs), referred to in this setting as immune restoration disease (IRD). We examined the risk of developing IRD in HAART-treated HIV-infected patients. METHODS: A retrospective study of a cohort including all 389 patients treated with HAART between 1 January 1998 and 31 May 2004 in our HIV unit was performed to evaluate the occurrence of and risk factors for IRD during HAART. Baseline and follow-up values of CD4 T-cell counts and plasma viral loads (pVLs) were compared to assess the success of HAART. RESULTS: During successful HAART (significant increase in CD4 T-cell counts and decrease in pVL), at least one IRD episode occurred in 65 patients (16.7%). The median time to IRD was 4.6 months (range 2-12 months). IRDs included dermatomal herpes zoster (26 patients), pulmonary tuberculosis (four patients), tuberculous exudative pericarditis (two patients), tuberculous lymphadenitis (two patients), cerebral toxoplasmosis (one patient), progressive multifocal leucoencephalopathy (PML) (one patient), inflamed molluscum (one patient), inflamed Candida albicans angular cheilitis (three patients), genital herpes simplex (two patients), tinea corporis (two patients), cytomegalovirus (CMV) retinitis (two patients), CMV vitritis (one patient) and hepatitis B (three patients) or C (fifteen patients). A baseline CD4 T-cell count below 100 cells/microL was shown to be the single predictor [odds ratio (OR) 2.5, 95% confidence interval (CI) 0.9-6.4] of IRD, while a CD4 T-cell count increase to >400 cells/microL, but not undetectable pVL, was a negative predictor of IRD (OR 0.3, 95% CI 0.1-0.8). CONCLUSIONS: To avoid IRD in advanced patients, HAART should be initiated before the CD4 T-cell count falls below 100 cells/microL.     

Kinetics of indium-111-labelled platelets in HIV-infected patients with and without associated thrombocytopaenia.

Seven to 12% of HIV-infected patients have thrombocytopaenia. The pathophysiology of the thrombocytopaenia is not clear. It has been variously suggested that it may be caused by an increased peripheral platelet destruction, a defect in platelet production, or by a combination of these. The aim of the study was to elucidate the pathogenesis of HIV-associated thrombocytopaenia. We determined the mean platelet life span (MPLS) and calculated the turnover of autologous indium-111-labelled platelets in 17 HIV-positive patients, seven with thrombocytopaenia. The sites of sequestration of labelled platelets were quantified. The thrombocytopaenic patients had a very short MPLS (3.0+/-3.8 h) and a marked increase in platelet production (18.2+/-12.6x10(9)/l/h). The majority of these patients (5 of 7) had excessive sequestration of platelets in the spleen. Five of the patients with a normal blood platelet count had a shortened MPLS (109+/-23 h) and increased platelet turnover (3.8+/-1.2x10(9)/l/h), i.e. the increased peripheral platelet destruction was compensated for by increased platelet production. The other five patients with a normal platelet count had normal MPLS (195+/-11 h) and slightly increased platelet production (2.5+/-0.6x10(9)/l/h). We conclude that patients with HIV-associated thrombocytopaenia have increased peripheral platelet destruction. Platelet production is elevated but is insufficient to maintain a normal peripheral platelet count. In these patients platelets are predominantly sequestrated in the spleen. Patients with HIV infection and a normal blood platelet count may also have increased platelet production. This may be an early subclinical phase in the development of full-blown HIV-associated thrombocytopaenia.     

Peripheral arterial disease in HIV-infected and uninfected women

OBJECTIVE: Although HIV infection has been associated with increased risk of subclinical atherosclerosis and cardiovascular events, peripheral arterial disease (PAD) has not been assessed in HIV-infected patients. The objective of this study was to determine the prevalence of, and risk factors for, PAD using ankle-brachial index (ABI) measurement in HIV-infected and uninfected women. METHODS: ABI was determined for 335 participants in the Women's Interagency HIV Study (WIHS). A cross-sectional analysis was conducted to determine factors associated with high (>or=1.40) ABI. RESULTS: The prevalence of low ABI (or=1.40) was 6.9% (n=23). The prevalence of low ABI was too low to allow risk factor analysis. On multivariate analysis, factors associated with high ABI were current cigarette smoking [adjusted odds ratio (OR(adj)) 2.53, 95% confidence interval (CI) 0.99-6.43], being underweight (OR(adj) 11.0, 95% CI 1.61-75.63) and being overweight (OR(adj) 5.40, 95% CI 1.13-25.89). CONCLUSIONS: Although the prevalence of ABI or=1.40 was unexpectedly high. Further studies are indicated to determine the clinical significance of high ABI and its relation to the risk of cardiovascular events in HIV-infected women.     

The influence of espresso coffee on neurocognitive function in HIV-infected patients

The aim of our study was to evaluate the impact of coffee intake on cognitive function in persons living with HIV (PLWH). 130 PLWH with CD4?>?200?cells/mm³, undetectable viral load, treated with HAART were included. A structured interview was applied and relevant clinical and laboratory data were assessed, including coffee intake. For neuropsychological assessment, the HIV Neurobehavioral Research Center Battery was chosen. Univariate nonparametric statistics and multivariate regression model were used. A significant association between espresso coffee use and a better cognitive function was verified in five of the eight psychometric measurements. In the multivariate analysis, after variable adjustment, linear regression analysis showed that coffee intake was a positive predictor for attention/working memory, executive functions and Global Deficit Score. Although the mechanisms behind the influence of caffeine on cognitive functioning are controversial, regular espresso coffee intake may have favourable effects on cognitive deterioration caused by HIV.