The impact of HIV infection on primary headache. Unexpected findings from retrospective, cross-sectional, and prospective analyses

Headache is one of the most important factors influencing the quality of life in patients infected with the human immunodeficiency virus type 1 (HIV). However, only symptomatic headache but not changes or primary headache types during HIV infection have been studied to date. Therefore, we aimed to determine the impact of an HIV infection on frequency and semiology of different primary headache types. Patients with confirmed HIV type 1 infection underwent a neurological examination, neuroimaging or EEG, and a standardized interview. Time pattern and symptoms of headaches (cross-sectional analysis), changes of headaches preexisting to their infection (longitudinal retrospective analysis), and changes of primary headaches during a 2-year follow-up (longitudinal prospective analysis) were evaluated as were the correlations between these headache patterns and different markers of HIV infection. One hundred thirty-one consecutive HIV-infected patients without evidence of a cerebral manifestation except mild encephalopathy were enrolled. The point prevalence of migraine was 16.0% (confidence interval (CI) 10.1-25.4%), of headache with a semiology of tension-type headache 45.8% (CI 33.7-62.2%), and of other headache types 6.1% (CI 3.0-12.5%). During the natural course of infection, the migraine frequency significantly decreased in the retrospective and in the prospective analyses, whereas the frequency of the headache with a semiology of tension-type headache significantly increased in all three analyses. In 20% of all patients, the tension-type headache could be considered as symptomatic due to the infection but not due to focal or general cerebral lesions. Changes of primary headache were significantly associated with different stages of the infection and with the presence of mild encephalopathy but not with antiretroviral treatment or CD4 cell count. HIV infection seems to be associated with a progressive decrease in migraine frequency and intensity which probably is related to the immunological state of the patients. Tension-type headache becomes more frequent during HIV infection. However, this can in part be related to secondary headache caused by the HIV in less than 50% of patients with tension-type headache. The progressing immunological deficiency of HIV-infected patients seems to influence pain processing of primary headache types in different ways.     

Kryptokokkenmeningoenzephalitis von HIV-infizierten Immigranten¶Diagnostische und therapeutische Aspekte unter Berücksichtigung der “evidence-based medicine”– Ein Überblick

Zusammenfassung Die Kryptokokkenmeningoenzephalitis ist eine der h?ufigsten Meningoenzephalitiden von AIDS-Patienten. Ihre H?ufigkeit betrug vor der Einführung der Triazol-Antibiotika wie Difluconazol 5–10% aller AIDS-Patienten, sank jedoch in den letzten Jahren. Klinisch imponieren meist unspezifische Zeichen einer meningealen Reizung, w?hrend fokale neurologische Symptome selten sind. Prognostisch entscheidend für die mit einer hohen Mortalit?t verbundenen Erkrankung sind eine rechtzeitige, hochdosierte Antimykotikatherapie, die derzeit üblicherweise mit Amphotericin B, Flucytosin und Fluconazol durchgeführt wird. Der Nachweis von Kryptokokken-Antigen im Liquor, die Darstellung von Kryptokokken im Tuschepr?parat und die üblicherweise positive Liquor-Kryptokokkenkultur best?tigen die klinische Verdachtsdiagnose. Aktuelle Entwicklungen zielen auf Optimierung der antimykotischen Therapie. In den letzten Jahren wurde die lebenslange Terti?rpr?vention mit Difluconazol oral etabliert. Mittelfristig wird die Prognose der Patienten von der zugrundeliegenden Immunsuppression bestimmt, so da? nach erfolgreicher Therapie eine moderne antivirale Kombinationstherapie zus?tzlich zur Terti?rpr?vention dringend indiziert ist. Die vorliegende übersicht thematisiert Entscheidungssituationen in der Behandlung von Patienten mit Kryptokokkenmeningoenzephalitis anhand von Prinzipien der “evidence-based medicine”.      

Cidofovir (Vistide®) in der Therapie der Progressiven multifokalen Leukoenzephalopathie (PML) bei AIDSLiteraturübersicht und Beschreibung zweier Fälle

Zusammenfassung Die Progressive Multifokale Leukoenzephalopathie (PML), eine durch das JC-Virus hervorgerufene Enzephalitis, tritt bei etwa 4%–5% aller HIV-1-infizierten Personen auf und hat mit einer mittleren postdiagnostischen überlebenszeit von 3 bis 6 Monaten eine ?u?erst schlechte Prognose. Bis heute existiert keine effektive Therapie der PML, Therapieversuche an kleineren Kollektiven mit a-Interferon, Didanosin und Arabinosid hatten nur wenig Erfolg. In einer kontrollierten Studie mit Cytarabin konnte keine Wirksamkeit dieses Medikamentes gegen die PML beobachtet werden. Erste Einzelfallbeschreibungen über eine Therapie der PML mit Cidofovir (Vistide^?), einem für die Zytomegalie-Retinitis bei AIDS-Patienten ohne renale Dysfunktion zugelassenen Nukleotid-Analogon, zeigten positive Ergebnisse. Wir berichten über zwei weitere F?lle der Behandlung einer AIDS-assoziierten PML mit Cidofovir. Von 22 in der Literatur beschriebenen F?llen einer Behandlung der AIDS-assoziierten PML mit Cidofovir – einschlie?lich der beiden hier beschriebenen F?lle – haben sich 16 Patienten unter der Therapie gebessert, 2 Patienten zeigten eine stabile Symptomatik und nur 4 Patienten verschlechterten sich weiterhin fulminant. Diese Ergebnisse deuten darauf hin, da? Cidofovir einen antiviralen Effekt auch auf das JC-Virus ausübt, der in der Therapie der PML bei Patienten mit AIDS genutzt werden sollte, da bisher kaum therapeutische Alternativen bestehen. Ob andere Faktoren für die klinische Verbesserung der 16 bisher beschriebenen F?lle unter einer Therapie mit Cidofovir mitverantwortlich sind oder ob die klinische Verbesserung ein alleiniger Effekt der Therapie mit Cidofovir ist, mu? letztlich offen bleiben und in einer randomisierten, kontrollierten Studie mit gro?er Patientenzahl gekl?rt werden.      

CAS-System MKM(R): use and results in lateral skull base surgery

BACKGROUND: Computer assisted surgery has reached an advanced stage of development and offers new possibilities in daily surgical procedures. METHODS: The MKM(R) - is a navigation system fitted with a laser-guided, autofocus-microscope for referencing purposes. The coordinates can be set using various marker systems and a special workstation is used for preoperative planning. It is possible to add landmarks and display them in the surgeon's eyepiece. The clinical integration, the time required for the use of the navigation system and the intraoperative accuracy of the system were evaluated on the basis of 136 lateral skull base procedures. RESULTS: The degree of accuracy is determined by the type, amount and positioning of markers. The adjustment of reference points should be carried out following macrosurgery in order to avoid shifting factors. For an additional increase in accuracy, an improvement in the spatial resolution of the CT scans is required, with a section thickness of 1 mm and a pixel size of 0.5mm. The bone-anchored structures of the temporal bone do not underlie shifting or extensive intraoperative swelling. Skull base surgery is, therefore, ideally suited for the application of CAS. We found that registration was accurate to less than 1 mm (0.68 mm +/- 0.17 mm) and that the MKM(R) system made an additional contribution to surgical safety by identifying important structures. CONCLUSIONS: A practical accuracy found to be approximately one millimetre suggests that the non-invasive referencing system may be effective, accurate and useful for computer assisted identification of vital structures. We expect navigation systems to improve the quality and reduce the risks of surgical intraventions.     

Study of the three-dimensional geometry of the central conducting airways in man using computed tomographic (CT) images

Clinical research on the deposition of inhaled substances (e.g. inhaled medications, airborne contaminants, fumes) in the lungs necessitates anatomical models of the airways. Current conducting airway models lack three‐dimensional (3D) reality as little information is available in the literature on the distribution of the airways in space. This is a limitation to the assessment or predictions of the particle deposition in relation to the subject’s anatomy. Detailed information on the full topology and morphology of the airways is thus required to model the airway tree realistically. This paper presents the length, diameter, gravity, coronal and sagittal angles that together describe completely the airways in 3D space. The angle at which the airways branch out from their parent (branching angle) and the rotation angle between successive bifurcation planes are also included. These data are from the study of two sets of airways computed tomography (CT) images. One CT scan was performed on a human tracheobronchial tree cast and the other on a healthy male volunteer. The airways in the first nine generations of the cast and in the first six conducting generations of the volunteer were measured using a computer‐based algorithm. The data contribute to the knowledge of the lung anatomy. In particular, the spatial structure of the airways is shown to be strongly defined by the central airways with clear angular lobar patterns. Such patterns tend to disappear with a mean gravity, coronal and sagittal angles of 90° in each generation higher than 13–15. The mean branching angle per generation appears independent of the lobe to which the airways belong. Non‐planar geometry at bifurcation is observed with the mean (± SD) bifurcation plane rotation angle of 79 ± 41° (n = 229). This angle appears constant over the generations studied. The data are useful for improving the 3D realism of the conducting airway structure modelling as well as for studying aerosol deposition, flow and biological significance of non‐planar airway trees using analytical and computational flow dynamics modelling.     

The diagnostic reliability of the occipitomental radiograph of the paranasal sinuses. Correlation with magnetic resonance tomography]

100 conventional occipitomental radiographs of the paranasal sinuses were studied independently by five radiologists. Predictive values were determined, based on MRI as the gold standard. Sensitivity and specificity for detection of mucosal thickening in the sinuses were: maxillary sinus: 0.73/0.76, frontal sinus: 0.20/0.85, ethmoid sinus: 0.38/0.87, sphenoid sinus: 0.14/0.96. In the maxillary sinus polypoid thickening was demonstrated with a significantly higher sensitivity than that of diffuse mucosal thickening (0.82 versus 0.65, Chi-square-test, p less than 0.01). Because of the low predictive values the occipitomental view is insufficient to assessing mucosal thickening in the paranasal sinuses, with the exception of polypoid mucosal thickening in the maxillary sinus.