Immunosuppression among HIV‐1‐positive patients attending for care: experience from two large HIV centres in the United Kingdom

Objectives

The aim of the study was to describe the prevalence of and examine the factors associated with immunosuppression (CD4<200 cells/μL) among HIV‐infected patients attending two large inner London treatment centres.

Methods

Patients attending for care who had a CD4 count <200 cells/μL during a 6‐month period (1 January to 30 June 2007) were identified from the UK national CD4 surveillance database. Corresponding case notes were reviewed and factors associated with the most recent immunosuppressive episode examined. Patients either previously had a CD4 count >200 cells/μL at any time under follow‐up which had decreased (group A) or never had a CD4 count >200 cells/μL (group B; late presenters).

Results

Of 4589 patients, 10.2% (467) had at least one CD4 count <200 cells/μL. In group A (60.1% of patients), 70.4% were not receiving antiretroviral therapy (ART) at the time at which the CD4 count fell to <200 cells/μL. Reasons included: treatment interruption (TI; 32.6%), patient declined ART (20.2%), infrequent attendance (19.1%), physician delay in offer (23.1%) and transient CD4 cell count decrease (3.9%). Among those receiving ART, one in three had poor adherence. In group B, 92.3% had started ART after presentation: most had recently started and were responding virologically. AIDS‐defining diagnoses occurred in the year preceding the decrease in CD4 cell count in 12.6% of patients in group A and 33.3% of those in group B.

Conclusion

The majority of patients became immunosuppressed while under care. Our findings suggest that, in addition to strategies aimed at earlier diagnosis, there are further opportunities to reduce severe immunosuppression in patients already attending for HIV care.     

Large femoral bone loss after hip revision using the uncemented proximally porous-coated Bi-Metric prosthesis: 22 hips followed for a mean of 6 years

Background and purpose Periprosthetic bone loss after uncemented femoral hip revision is a matter of concern. We have used a proximally porous- and hydroxyapatite-coated prosthesis (Bi-Metric) in revision since 1989 and now we report the bone changes. This prosthesis is intended to distribute the forces more evenly and to avoid proximal femoral unloading.Methods 22 patients were unilaterally reoperated because of aseptic loosening. Only patients with a healthy contralateral hip were included. Mean age at revision was 69 (55–80) years. Bone defects were graded by Gustilo-Pasternak and Endo-Klinik classifications. Clinical assessment was performed with Harris hip score. We used radiographs and dual-energy X-ray absorptiometry to evaluate migration, femoral remodeling, and bone mineral density after 72 (30–158) months.Results The mean Harris hip score was 74 (30–100) points at follow-up. Mild thigh discomfort was present in 1 patient and moderate thigh pain in 3 patients. There was no loosening or subsidence. Osteolysis seen at revision had diminished in 19 of the 22 hips at follow-up. We noted a large reduction in bone mineral density. It was most pronounced in Gruen regions 1, 2, 6, and 7.Interpretation Revision with this stem is a reliable procedure; however, we noted a large degree of proximal bone loss that could lead to later mechanical complications or fractures.     

Current role of bloodless liver resection

Liver resections are demanding operations which can have life threatening complications although they are performed by experienced liver surgeons. Recently new technologies are applied in the field of liver surgery, having one goal： safer and easier liver operations. The aim of this article is to address the issue of bloodless liver resection using radiofrequency energy. Radionics, Cool-tip^TM System and Tissue Link are some of the devices which are using radiofrequency energy. All information included in this article, refers to these devices in which we have personal experience in our unit of liver surgery. These devices take advantage of its unique combination of radiofrequency current and internal electrode cooling to perform sealing of the small vessels and biliary radicals. Dissection is also feasible with the cool-tip probe. For the purposes of this study patient sex, age, type of disease and type of surgical procedure in association with the duration of parenchymal transection, blood loss, length of hospital stay, morbidity and mortality were analyzed. Cool-tip RF device may provide a unique, simple and rather safe method of bloodless liver resections if used properly. It is indicated mostly in cirrhotic patients with challenging hepatectomies （segment Ⅷ, central resections）. The total operative time is eliminated and the average blood loss is significantly decreased. It is important to note that this technique should not be applied near the hilum or the vena cava to avoid damage of these structures.     

Transarterial embolization of giant liver hemangiomas associated with Kasabach-Merritt syndrome: a case report

Of 22 patients with symptomatic giant liver hemangiomas referred for embolization, two females (52 and 74 years) had Kasabach-Merritt syndrome (KMS). Hematocrit values were observed to be 33% and 29%, platelets 4000 and 5400/mm(3), and fibrinogen 98 and 77 mg/dl, respectively. Lesion diameters were 7 and 14 cm, respectively. Hepatic angiography revealed excessive vascular lakes typical of cavernous hemangiomas. Microspheres of 40-300 microm were superselectively injected under fluoroscopic guidance until cessation of flow. Coil packing of the feeding hepatic artery was additionally used in one patient. The procedure was uneventful in both. Partial restoration of platelet count was observed immediately; fibrinogen levels and platelets were restored completely in one patient and partially in the other, without remissions at 2-year follow-up.     

Injection drug use among street-involved youth in a Canadian setting

Background  

Street-involved youth contend with an array of health and social challenges, including elevated rates of blood-borne infections and mortality. In addition, there has been growing concern regarding high-risk drug use among street-involved youth, in particular injection drug use. We undertook this study to examine the prevalence of injection drug use and associated risks among street-involved youth in Vancouver, Canada.     

Unstable housing and hepatitis C incidence among injection drug users in a Canadian setting

Background  

There has emerged growing recognition of the link between housing and health. Since Vancouver, Canada has had increasing concerns with homelessness brought about by urban renewal in the lead-up to the 2010 Winter Olympic Games, we evaluated hepatitis C virus (HCV) incidence among injection drug users (IDU) with and without stable housing.     

Discriminant validity and neuroanatomical correlates of rule monitoring in frontotemporal dementia and Alzheimer's disease

Despite the predominant frontal neuropathology of frontotemporal dementia (FTD), traditional measures of executive functioning do not reliably distinguish FTD from Alzheimer's disease (AD). Performance monitoring is an executive function that is associated with frontal lobe integrity and may be disrupted in FTD. The current study adopted a component process approach to evaluate the discriminant validity and neuroanatomical correlates of performance monitoring (i.e., rule monitoring) during an executive spatial planning task. Forty-four participants with FTD, 30 with AD, and 27 healthy comparison (HC) subjects completed the Delis-Kaplan Executive Function System (D-KEFS) Tower task. A subset of patients underwent structural magnetic resonance imaging to obtain regional measures of cortical volumes. FTD and AD groups demonstrated significantly poorer overall achievement scores on the Tower test relative to the HC sample, but did not differ from one another. In contrast, the FTD group committed significantly more rule violation errors than both HC and AD groups, indicating poorer performance monitoring. In addition, poorer overall achievement correlated with smaller brain volumes in several regions, including bilateral frontal and parietal regions, whereas an increased number of rule violations correlated specifically with decreased bilateral frontal volume. Both left and right frontal volumes remained significant predictors of rule violation errors after controlling for the contribution of overall achievement on the task and all other brain regions. Findings are consistent with literature implicating the frontal lobes in performance monitoring and highlight the importance of characterizing the component processes of performance failures in the cognitive assessment of FTD and AD.     

Surgical management of large adrenal tumours: the University of Miami experience using liver transplantation techniques

OBJECTIVE

To report our experience in the surgical management of patients with large adrenal masses and describe the key steps in performing radical resections, which are especially demanding where thrombi extend into the inferior vena cava (IVC).

PATIENTS AND METHODS

From 2003 to 2007, 14 patients presented with large adrenal mass, and underwent surgical extirpation. In five patients thrombi extended into the IVC, causing Budd–Chiari syndrome in one.

RESULTS

The median (range) patient age was 48 (40–58) years. The excision was radical with negative tumour margins in all cases. Cardiopulmonary bypass (CPB) was required in one case with adherent intra‐atrial thrombus. The mean blood loss was 500 (250–1500) mL except in the patient who required CPB. Morbidity included pleural effusion (three patients) and postoperative pneumonia (two), which responded to conservative management. All patients were alive and free of disease at a median follow‐up of 12 (5–42) months.

CONCLUSIONS

Surgical extirpation of large adrenal masses requires technical experience to optimize outcome. Total tumour excision is the only therapeutic option in such cases and provides acceptable results in survival and quality of life.