Prevalence of HIV-associated lipodystrophy in Brazilian outpatients: relation with metabolic syndrome and cardiovascular risk factors

Lipodystrophy in HIV-infected patients (LDHIV) affects 40-50% of HIV-infected patients, but there are no data on its prevalence in Brazil. The aim of this study was to assess the LDHIV prevalence among HIV-infected adult Brazilian individuals, as well as to evaluate LDHIV association with cardiovascular risk factors and the metabolic syndrome (MS). It was included 180 adult HIV-infected outpatients consecutively seen in the Infectology Clinic of Universidade Estadual de Londrina. Anthropometric and clinical data (blood pressure, family and personal comorbidities, duration of HIV infection/AIDS, antiretroviral drugs used, CD4+ cells, viral load, fasting glycemia and plasma lipids) were obtained both from a clinical interview as well as from medical charts. LDHIV was defined as the presence of body changes self-reported by the patients and confirmed by clinical exam. MS was defined using the NCEP-ATPIII criteria, reviewed and modified by AHA/NHLBI. A 55% prevalence of LDHIV was found. Individuals with LDHIV presented a longer infected period since HIV infection, longer AIDS duration and longer use of antiretroviral drugs. In multivariate analysis, women (p=0.006) and AIDS duration >8 years (p<0.001) were independently associated with LDHIV. Concerning MS diagnostic criteria, high blood pressure was found in 32%, low HDL-cholesterol in 68%, hypertriglyceridemia in 55%, altered waist circumference in 17% and altered glycemia and/or diabetes in 23% of individuals. Abnormal waist and hypertriglyceridemia were more common in LDHIV-affected individuals. MS was diagnosed in 36%. In multivariate analysis, the factors associated with MS were: BMI >25 kg/m(2) (p<0.001), family history of obesity (p=0.01), indinavir (p=0.001) and age >40 years on HIV first detection (p=0.002). There was a trend to higher frequency of LDHIV among patients with MS (65% versus 50%, p=0.051). LDHIV prevalence among our patients (55%) was similar to previous reports from other countries. MS prevalence in these HIV-infected individuals seems to be similar to the prevalence reported on Brazilian non-HIV-infected adults.     

Further evidence of the in vivo role of erythropoietin or companion molecules induced by hypoxia on proliferation and continuing differentiation of BFU-e in PCDC

Normal and plethoric bone marrow cells were grown in plasma clot diffusion chambers (PCDC) implanted into the peritoneum of normal mice or mice submitted to 7 her of hypoxia (23,000 ft) daily, on a single day or on 2 consecutive days at different times after implantation of the PCDC's. Daily discontinuous hypoxia (DDH) produced more 6-day bursts than other treatments. Hypoxia on days 1 and 2 after implantation was nearly as effective as DDH on day-6 bursts. Later bouts of hypoxia or a singly hypoxic exposure on day 1 or 2 was less effective. Erythropoietin (Ep) levels were measured by bioassay on both diffusion chamber (DC) contents and serum. Serum Ep levels peaked at 160 mU/ml after a 7-hr hypoxic exposure while the DC content Ep levels were in the nondetectable range (less than 50 mU/ml). The data implies that either higher than normal Ep levels or a companion molecules (s) produced by hypoxia are required for 1-2 days early in the culture period of force an increasing number of BFU-d-e down the erythrocytic pathway and thus increase red cell production at times of need in vivo.     

Pancreatic neuroendocrine tumor with ectopic adrenocorticotropin production upon second recurrence

We present a 54-yr-old woman with ectopic corticotropin syndrome caused by a neuroendocrine tumor of the pancreas. At initial presentation, the patient suffered from diarrhea, heartburn, and nonspecific abdominal pain. There was no evidence of Cushing's syndrome. A neuroendocrine tumor in the head of the pancreas with metastases into peripancreatic lymph nodes was diagnosed and completely resected. Fourteen months later, abdominal computed tomography and scintigraphy with (111)In-labeled octreotide suggested relapse of the tumor. The patient again had no evidence of Cushing's syndrome. A second in toto tumor resection was performed. Another 8 months later, the patient developed forgetfulness, depressive episodes, muscle weakness, new-onset hypertension, hypokalemia, plethora, diabetes mellitus, polyuria, and weight loss. Endocrine testing suggested a source of ectopic ACTH production. An octreotide scan showed an intense uptake ventromedial of the left kidney, an area that showed a mass lateral of the superior mesenteric artery on abdominal magnetic resonance imaging. A complete pancreatectomy with splenectomy and left-sided adrenalectomy were performed. At this second relapse, this neuroendocrine tumor clinically had changed its hormonal profile. Immunohistochemically, in contrast to primary tumor and first relapse, we found strong immunostaining for ACTH in tumor cells of the second relapse and a MIB-1 index greater than 20%. To our knowledge, this is the first report describing a pancreatic neuroendocrine tumor that started to secrete ACTH de novo at the time of the second relapse after two former complete tumor resections. This case underscores the pluripotency of neuroendocrine tumor cells and the importance of keeping in mind a possible shift in hormone production during tumor evolution and progression.     

Thalidomide as salvage therapy for chronic graft-versus-host disease

Thalidomide has been reported to be an effective agent for treatment of chronic graft-versus-host disease (CGVHD). To determine the efficacy of this agent in patients with refractory CGVHD a total of 80 patients who failed to respond to prednisone (PSE) or PSE and cyclosporine (CSA) were treated with thalidomide. Sixteen patients (20%) had a sustained response, 9 with a complete remission and 7 with a partial response. Twenty-nine patients (36%) had thalidomide discontinued because of side effects, which included sedation, constipation, neuritis, skin rash, and neutropenia. Side effects were reversible with drug discontinuation except for mild residual neuritis in one case. Rashes and neutropenia have not previously been reported as thalidomide side effects when used for CGVHD treatment. We conclude thalidomide is immunosuppressive and active in the treatment of CGVHD. A high incidence of reversible side effects limited dose intensity and reduced the number of patients who could benefit from treatment.     

Yearly diagnostic yield of colonoscopy in patients age 80 years or older,with a special interest in colorectal cancer

Aim: A high diagnostic yield of colonoscopy has been reported in elderly patients, but there is no data on the yearly yield. Our aim was to detect the yearly yield of colonoscopy in elderly patients. Methods: All consecutive endoscopies in the years 1992–2009 were included. Important endoscopic diagnoses were defined as colorectal cancer (CRC), polyps, diverticuli and inflammation. Results: In total, 19 569 endoscopies were performed, of which 1706 (8.7%) were in patients age 80 years or older. The number of women was significantly higher (P < 0.001). The percentage of patients who were 80 years or older was higher than in the general population and remained stable during the study period, though there has been a proportional increase of elderly people in the general population. Inconclusive procedures were present in 106 (6.2%) elderly patients compared with 277 (1.6%) patients under 80 years of age (P < 0.001). There were no significant changes in the consecutive years. A procedure revealing no endoscopic diagnosis was observed less often in patients who were 80 years or older (P < 0.001). CRC was diagnosed in 221 (19.6%) older patients. This figure remained more or less constant each year. Polyps were seen in 448 (8.8%) patients 80 years of age or older. The percentage of patients with diverticuli and inflammation was constant. The number of patients 80 years or older with CRC and polyps rose at a lower rate than the number of older people in the general population. Conclusion: The yield of colonoscopy in patients 80 years or older was high and constant over the years. The number of tumors rose less than expected compared to the increase of elderly in the general population. Geriatr Gerontol Int 2012; 12: 298–303.