Dyslipidaemia after switch to tenofovir alafenamide (TAF)-based cART regimens in a cohort of HIV-positive patients: what clinical relevance?

OBJECTIVES: Switching from tenofovir (TDF) to tenofovir alafenamide (TAF) affects lipid profile. The aim of this study was to evaluate whether this results in an increased frequency of patients with low-density lipoprotein (LDL) above their cardiovascular-related target. METHODS: All HIV patients switching from TDF to TAF, with no changes of the anchor drug, and with plasma lipids available within 6 months before and after the switch, were included. Demographic, HIV-related parameters, cardiovascular (CV) risk factors and lipid profile on both TDF and TAF were collected. The CV risk score and the relative target of LDL for each patient were calculated according to 2016 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for the management of dyslipidaemias. Modifications in lipid profiles and in the prevalence of patients with LDL above their CV-related target were evaluated after switch to TAF. RESULTS: Overall, 221 HIV patients were included, according to CV risk: 55% at low risk, 34% at moderate risk, and 11% at high/very high risk. By analysing lipid profiles according to CV risk, 38% of patients on TDF had LDL above their CV target; this prevalence increases to 60% after switching to TAF (P < 0.0001). The presence of cobicistat in the combination antiretroviral therapy (cART) regimen was associated with an increased risk of LDL above the CV-related target after switch to TAF [adjusted odds ratio (aOR) = 2.4, 95% confidence interval (CI): 1-5.1], P = 0.03) and with an increased prescription of lifestyle/therapeutic intervention (OR = 3.0, 95% CI: 1.7-5.3, P < 0.0001). DISCUSSION: Switching from TDF to TAF affects lipid parameters, and data from real life suggest a clinical relevance of this worsening that often leads clinicians to implement lifestyle/therapeutic interventions.

Assessment of radiological vertebral fractures in HIV-infected patients: clinical implications and predictive factors.

OBJECTIVES: The aim of this study was to evaluate the clinical impact of including lateral spine X-ray in the screening of bone diseases in HIV-positive patients. METHODS: A total of 194 HIV-positive patients underwent dual-energy X-ray absorptiometry (DEXA), lateral spine X-ray and bone biochemical analysis. Vertebral fractures were identified using a morphometric analysis of X-rays and classified using the semiquantitative scoring system of Genant et al. For each patient, a spine deformity index (SDI) score was calculated by summing the grades of vertebral deformities. Reductions in vertebral body height of > 25% were considered vertebral fractures, and those < 25% were considered vertebral deformities. Risk factors associated with vertebral fractures were evaluated by univariate and multivariate analysis. RESULTS: Vertebral fractures were detected in 24 patients (12.4%) and vertebral deformities in 17 patients (8.7%); 153 patients (78.9%) did not show any vertebral deformity. Among patients with fractures, only two with SDI > 10 reported lumbar pain; the remaining were asymptomatic. Patients over 50 years old showed a higher prevalence of vertebral fracture [24.4% versus 11.8% in patients 41-50 years old (P = 0.05) and 1.9% in patients ≤ 40 years old (P = 0.04)]. No significant increase in the prevalence according to bone mineral density (BMD) reduction was observed, and 70% of fractures were diagnosed in nonosteoporotic patients. Older age [adjusted odds ratio 1.09; 95% confidence interval (CI) 1.03-1.13; P = 0.001] and steroid use (adjusted odds ratio 3.64; 95% CI 1.29-10.3; P = 0.01) were independently associated with vertebral fracture; no association was found with HIV- or highly active antiretroviral therapy (HAART)-related variables. CONCLUSIONS: A prevalence of vertebral fractures of 12.4% was observed in our HIV-positive cohort. Given that two-thirds of fractures occurred in nonosteoporotic patients, spine X-ray may be considered in patients at increased risk, irrespective of BMD; that is, in elderly patients and/or patients using steroids.

[Surgical treatment of exogenous morbid obesity: results of Mason's vertical gastroplasty]. / Traitement chirurgical de l'obésité morbide exogène: résultats de la gastroplastie verticale selon Mason.

Among the various surgical methods of treating exogenous morbid obesity, Mason's vertical gastroplasty has gradually become the method of choice throughout the world. The method is relatively simple and the operating time short, so that if offers the great advantage of maintaining normal digestive activity free of metabolic disturbances. Between December 1981 and December 1988 we treated 160 patients in this way, the mortality in the series being nil. The results obtained are encouraging, since among 75 patients followed up for at least 2 year, 50 (66%) had a weight index between 20 and 25, 15 (20%) a weight index between 25 and 30, while 10 patients (14%) failed to respond to the treatment.

[The intragastric balloon: a logical and attractive idea, but probably ineffective]. / Le ballon intragastrique: une idée logique et séduisante, mais probablement inefficace.

Loss of post prandial satiety is often of limiting value in the success of a slimming training. Thus, the idea to introduce a balloon filled partially with air to occupy the stomach seems to be logic. A technic easy to handle had contributed to a large diffusion of this method before people asked about its real efficacy. Several short term (10 days) or medium term (6-10 months) studies show a significant weight loss, but there have been no controlled trials to determine the relative contribution to weight loss of the gastric balloon vs dietary and behaviour modifications. Furthermore, a great variability in the weight loss, some subjects even gaining weight, suggest that the compliance of the patients may be the most relevant factor. Adverse effects are effectively low and principally concern local gastric irritation (2-5%) and intestinal occlusion in some rare cases requiring surgical removal of the partially deflected balloon. Thus, if the implantation of a gastric balloon is relatively safe, it is difficult to recommend its use to the treatment of obesity in regard of the actual published results, even if most of the treated patients suffered of refractory obesity, difficult to modify with non surgical treatment.

Nosocomial bacterial pneumonia in HIV-infected patients: risk factors for adverse outcome and implications for rational empiric antibiotic therapy.

BACKGROUND: Nosocomial bacterial pneumonia (NBP) was once considered a common cause of morbidity and mortality among advanced AIDS patients. However, clinical and microbiological characteristics and outcome-associated risk factors in this population are poorly defined. PATIENTS: We conducted a retrospective study of all HIV-infected patients admitted during the period 1988-2002 at the Infectious Diseases Clinic of Milan, Italy, to determine incidence rate and factors affecting mortality of NBP, and to gather clinical and microbiological findings about the condition. RESULTS: We identified 120 episodes of NBP among 4,967 admissions of HIV-infected individuals. A reduction of incidence became evident after the introduction of highly active antiretroviral therapy (HAART). The more common causative agents were Pseudomonas aeruginosa (33%) Staphylococcus aureus (25%) and Streptococcus pneumoniae (21%). Methicillin resistance was frequent among staphylococci (65%). The mortality rate of NBP was 25.8%. Non-statistically significant factors associated with shorter survival were: CD4(+) count < 10 cells/microl, concomitant lung neoplasm, and complicated roentgenographic picture. Only one factor was significantly associated with lower survival, both in univariate and multivariate analysis: a methicillin-resistant Staphylococcus serving as an etiologic agent of pneumonia (RR 4.05; 95% CI, 1.076-15.239; p = 0.039). CONCLUSION: A decline in incidence of NBP in HIV-infected individuals was observed after introduction of HAART. S. aureus and P. aeruginosa were the leading causes of NBP, but frequency of pneumococcal pneumonia was significant. The sole predictor for mortality was methicillin-resistant Staphylococcus as a pneumonia-causing agent.

Cancer of the gastric stump following operations for benign gastric or duodenal ulcers.

Twenty-seven patients who developed cancer of the stomach after undergoing gastric resection (GR), gastroenterostomy (GE), and vagotomy and pyloroplasty (VP) for benign gastric or duodenal ulcer are reported. The etiology and the pathogenesis of this type of cancer are discussed. Long-term exposure of the gastric mucosa to bile and duodenal and pancreatic secretion reflux seems to create a premalignant potential state. Symptoms and the diagnostic methods of radiologic series, cytology, and endoscopy are discussed. We suggest a curative operative approach and discuss the poor value of palliative procedures. We emphasize the necessity of determining the prognosis with exploratory laparotomy which establishes at the same time the certitude of the diagnosis.

Long-term Results on Quality of Life of Surgical Treatment of Obesity with Vertical Banded Gastroplasty.

BACKGROUND: Few papers assess quality of life after vertical banded gastroplasty (VBG). METHODS: 100 patients with severe obesity (preoperatively mean BMI 41.7 kg m(2)) answered an interview 60 (+/- 2.5) months after VBG. RESULTS: There was no fatal outcome. Nine patients had pulmonary embolus; ten patients required reoperation because of stomal stenosis. Of the 89 patients that still bore a gastroplasty at the moment of the interview, 65 had lost more than 40% of their excess weight (= "success'). Improvement in quality of life of these 89 patients was reflected by significant diminution of depression and back pains. Significant diminution of arterial hypertension and improvement of professional satisfaction, and of social, physical, and sexual activity was significantly related to weight loss. CONCLUSION: VBG resulted generally in a favorable long-term effect on quality of life. However, patients should be informed preoperatively about potential side-effects such as possible persistent vomiting after several years, esophagitis and gastritis, restriction in the choice of foods and prolongation of meals.