Antiretroviral therapy. Immune restoration disease in HIV-infected patients on HAART

Inflammatory diseases related to a preexistent or subclinical infection with an opportunistic pathogen in patients with HIV infection who respond to HAART may be caused by the restoration of an immune response against the pathogen. One danger can be misinterpreting the patient's condition as evidence of treatment failure and then stopping the drug regimen. Instead, measurement of pathogen-specific immune responses may help in the diagnosis of immune restoration diseases. The next step may be to continue HAART and therapy for the related infection and add anti-inflammatory drugs, such as corticosteroids. Generally, antiretroviral therapy should only be stopped, even temporarily, if that approach fails.     

Hemispheric asymmetries in arousal affect outcome of the intracarotid amobarbital test.

OBJECTIVE: To evaluate changes in arousal and their impact on memory performance during the intracarotid amobarbital test (IAT). METHODS: Along with memory measures, level of arousal was evaluated through clinical ratings and nonverbal self-ratings in epilepsy patients undergoing IAT before anterior temporal lobectomy. RESULTS: Irrespective of seizure focus, left-sided amobarbital injection resulted in decreased objective and subjective arousal more often than right-side injection. Impaired objective arousal was greater when the left hemisphere was injected second, because of the presumed additive effects of systemic amobarbital residual from the first injection. Decreased objective arousal was related to poorer performance on memory testing following left-hemisphere injection. CONCLUSIONS: The IAT, as practiced in most centers, is biased, so patients with right temporal lobe seizure focus are more likely to "pass" the test, whereas patients with left seizure focus are more likely to "fail" the test. The significant impact of changes in arousal on memory testing needs to be considered when using IAT results to select patients for temporal lobectomy.     

Evidence-based guidelines for the management of genital chlamydial infection in general practice. (Leicestershire Chlamydia Guidelines Group).

BACKGROUND: Valid clinical guidelines can be effective in improving patient care. Genital Chlamydia trachomatis infection is the commonest curable sexually transmitted disease (STD) in England and Wales and is an important cause of pelvic inflammatory disease (PID), tubal infertility and ectopic pregnancy. No published guidelines exist on managing genital chlamydial infection in British general practice. OBJECTIVE: We aimed to develop valid guidelines for the management of genital chlamydial infection for use in British general practice. METHODS: A district-wide postal questionnaire survey was used to document current clinical practice. A critical review of the evidence concerning the management of genital chlamydial infection as it relates to British general practice was performed. The information gained from the critical review and survey was used to develop evidence-based guidelines within a multidisciplinary guideline recommendation group. RESULTS: The guidelines covered the diagnosis, investigation, drug treatment and referral of adult male and female patients with genital chlamydial infection in general practice. CONCLUSION: Valid guidelines for the management of genital chlamydial infection have been developed for use in British general practice. Appropriate dissemination and implementation of the guidelines should lead to earlier detection and treatment of men and women with chlamydial infection and thereby reduce the incidence of PID, tubal infertility and ectopic pregnancy in women.     

Back to the future for wound care?

The European Renaissance was a time of enormous change and rapid progress in the arts, sciences, and medicine. A glimpse of wound care in the last phase of the European Renaissance is provided by the analysis of work by Wilhelm Fabry, the "father of German surgery," as provided in his book De Combustionibus ("Burns") which details his range of treatments for the burn wound, as well as his approach to the later problems of scarring and contracture. We describe some of the historic events which may have stimulated Fabry's writings, in particular, the influences passed down from the medical school of Padua which thereby advanced the cause of wound care and surgery. Finally, we briefly explore the potential of such an approach to the works of our medical forefathers.     

Delayed evolution of posttraumatic subdural hygroma

Five hundred and forty-six patients in a consecutive series of 1,601 patients with craniocerebral trauma had computed tomography. One hundred and ninety-six patients had a follow-up CT scan. Thirteen patients (6.6%) developed apparently "silent" subdural hygromas of delayed evolution noted from six to 46 days after injury (average 22 days). Three of 10 patients (30%) improved after operation. No patient with a severe cerebral deficit (decortication or decerebration) improved. The three unoperated hygromas and the six that persisted after operation tended to resolve spontaneously. The infrequent and modest improvement following surgical treatment and the tendency to spontaneous resolution suggest that operation may be unnecessary in many patients with posttraumatic subdural hygroma of delayed evolution.