Discontinuation of Anticytomegalovirus Therapy in Patients With HIV Infection and Cytomegalovirus Retinitis

Context  Persons with cytomegalovirus (CMV) retinitis and acquired immunodeficiency syndrome (AIDS) have required lifelong anti-CMV therapy to prevent the progression of retinal disease and subsequent loss of vision. Objective  To determine whether patients who were taking highly active antiretroviral therapy (HAART) and who had stable CMV retinitis could safely discontinue anti-CMV therapy without reactivation of their retinitis or increase in human immunodeficiency virus (HIV) viral load. Design  Prospective nonrandomized interventional trial performed from July 1997 to August 1999. Setting  Clinical Center of the National Institutes of Health, Bethesda, Md. Patients  Fourteen patients with stable CMV retinitis and HIV infection and CD4⁺ cell counts higher than 0.15 x 10⁹/L and being treated with systemic anti-CMV medications and HAART. Interventions  Discontinuation of specific anti-CMV therapy. Main Outcome Measures  Reactivation of CMV retinitis, development of extraocular CMV infection, detection of CMV in blood and urine, HIV burden, immunologic function, quality of life, morbidity, and mortality. Results  Twelve (89.7%) of 14 patients had evidence of immune recovery uveitis before anti-CMV drugs were discontinued. No patient had reactivation of CMV retinitis or development of extraocular CMV disease during mean follow-up of 16.4 months (range, 8.3-22.0 months) without anti-CMV therapy. Human immunodeficiency viral load remained stable following cessation of anti-CMV medications. Blood and urine assays for CMV were briefly positive in 9 patients but did not predict reactivation of CMV disease. Worsening immune recovery uveitis was associated with a substantial (>3 lines) vision loss in 3 patients. Conclusions  Maintenance anti-CMV medications were safely stopped in those patients who had stable CMV retinitis and elevated CD4⁺ cell counts and who were taking HAART. The study demonstrates that immune recovery following potent antiretroviral therapy is effective in controlling a major opportunistic infection, even in patients with a history of severe immunosuppression.      

Dentine caries: take it or leave it?

In modern dentistry the primary aim when excavating carious dentine is to eradicate only the highly infected, irreversibly demineralised and denatured biomass in order to allow effective restoration of the cavity, restoration of the surface anatomy of the tooth and to prevent disease progression. However, the boundary between this superficial zone of dentine requiring excavation and the deeper, affected but repairable tissue is not always obvious either in the clinic or in the research laboratory. The inherent subjectivity in detecting this excavation boundary can result in clinically significant differences in the quality and quantity of dentine removed by different operators and makes the in vitro comparison of newer excavation techniques more difficult. This article discusses the rationale behind carious dentine excavation and the criteria available to the dentist, both clinical and laboratory, to help identify the dentine requiring removal.     

Emergency management of spinal cord injuries

The emergency nurse must anticipate the presence of SCIs. Spinal cord-injured patients should be considered acutely ill and assessed in a comprehensive manner. The occurrence of a SCI may mask symptoms of underlying pathologic conditions that, if left untreated, are life-threatening. The emergency nurse is in a pivotal role, whether functioning in a prehospital setting or in the ED, to intervene rapidly.     

Variability in the elimination of mianserin in elderly patients.

1. Two studies of the elimination of mianserin are reported. 2. In the first study, the oral clearance of mianserin was measured in 15 elderly patients at steady state. In a sub-group of eight patients who completed studies at two different doses there was evidence of enhanced oral clearance at the higher dose. 3. In the second study, the elimination half-life was estimated in 12 patients who were observed to have disproportionately high mianserin concentrations with respect to dose. All had half-lives greater than or equal to 2.5 days with a mean of 6 +/- 2.8 (s.d.) days. In six of the patients the profile of elimination was suggestive of saturable elimination. 4. The sparteine oxidation status was measured in seven of the patients showing slow mianserin elimination. Only one was a 'poor oxidiser' of sparteine, suggesting no concordance with this phenotype. 5. It is concluded that there is marked variability in the elimination of mianserin in elderly patients.     

Perceived control and involvement in self care in patients with colorectal cancer

Aim. This paper reports the qualitative findings from a mixed methods study which explored patients’ understandings of perceived control in relation to their self care during chemotherapy for colorectal cancer. Background. A greater degree of patient involvement in self care is increasingly being encouraged; however, little is known about how factors such as perceived control influence patients’ active involvement in self care. Design. Qualitative, longitudinal study. Methods. Semi structured interviews were conducted with 11 patients before and after six months of chemotherapy treatment for colorectal cancer in a Scottish cancer centre between March 2005–June 2006. The interviews, conducted as part of a larger study, explored patients’ understandings of their perceived control over managing treatment‐related side effects and how this influenced their attitudes toward, and role preferences in, self care. Results. Patients fell into one of two groups: ‘high’ or ‘low’ perceived controllers. High‐perceived controllers were more likely to view their active involvement in self care positively, as being necessary in managing treatment‐related effects and were less likely to rely on nurses to take overall responsibility for the management of treatment‐related side effects. Low‐perceived controllers were less likely to believe in the importance or necessity of their active involvement in self care and more likely to perceive nurses as being the ones responsible for the management of treatment‐related side effects. Conclusions. Perceived control during treatment for cancer influences patients’ perceptions toward, and role preferences in, self care. Relevance to clinical practice. Clinical interventions designed to enhance involvement in self care would benefit from focussing on enhancing patients’ perceived control and understanding their role preferences in self care. Patients with different understandings of perceived control may require different help and support to encourage their involvement in self care.     

INDUCED ANTIBODIES THAT REACT IN VITRO WITH SEDIMENTABLE CONSTITUENTS OF NORMAL AND NEOPLASTIC TISSUE CELLS : PRESENCE OF THE ANTIBODIES IN THE BLOOD OF RABBITS CARRYING VARIOUS TRANSPLANTED CANCERS

Antibodies were found in the blood of certain rabbits carrying one or another of four transplanted cancers (Brown-Pearce and V2 carcinomas; RSI and Kato sarcomas) which will fix complement in vitro in mixture with saline extracts of various normal and neoplastic rabbit tissues—including liver, kidney, spleen, and the four tumors mentioned—and chick embryo tissue as well. These antibodies, which have been called induced tissue antibodies, are similar to the natural antibodies previously described (2) in that they react with those constituents of the various tissue cells that prove readily sedimentable in the high speed centrifuge; they differ from the natural antibodies in being absent from the blood of normal rabbits and in withstanding 65° C. for 30 minutes. Certain quantitative differences suggest that the induced tissue antibodies have somewhat various affinities, depending in part upon the type of neoplasm carried by the host. They may perhaps be consequent on antigenic differences between the sedimentable constituents of the tumor cells and those of the new hosts; for they were not found in the blood of rabbits carrying papillomas and cancers composed of the animals'' own cells, and not in that of rabbits in which multiple vaccinia or fibroma virus lesions had recently regressed. The characters of the sedimentable constituents of normal and neoplastic tissue cells, as revealed thus far by chemical, morphological, and serological studies, have recently been discussed (2,8). In this relation, it has seemed essential to recognize the induced antibodies here described, particularly since they may complicate serological studies aimed at disclosing distinctive sedimentable substances in tissue cells. In an associated paper experiments are reported which bear upon the relation between the induced tissue antibodies and an antibody that reacts specifically with a distinctive sedimentable constituent of Brown-Pearce carcinoma cells (7).     

Family-genetic studies of psychiatric disorders. Developing technologies

During the past decade new concepts and technologies have improved the conduct of family-genetic studies in psychiatry. We compiled and critically evaluated these advances, including study design, pedigree collection, diagnostic procedures in adults and children, and epidemiologic and genetic approaches to data analysis. These approaches have improved the collection of accurate information on the nature and patterns of psychiatric illness in families. The data generated from well-designed and well-conducted family studies are useful for the identification of homogeneous subgroups of psychiatric disorders, for understanding the spectrum of psychiatric disorders, for examining the associations between psychiatric disorders, and for studying the continuity between adult and childhood manifestations of psychiatric disorders. Findings from these studies also may enhance our capacity to identify the mode of transmission of the psychiatric disorders and to select potentially informative families for future genetic linkage studies using the new recombinant DNA techniques. The adaptation of these methods to routine clinical practice and new directions in the application of family-genetic studies employing more refined assessments and analytic methods are also discussed.