Eosinophilia and associated factors in a large cohort of patients infected with human immunodeficiency virus.

OBJECTIVES: To determine the prevalence of eosinophilia among antiretroviral therapy (ART)-naïve patients infected with human immunodeficiency virus (HIV) and to identify variables associated with eosinophilia. METHODS: We included all ART-naïve HIV-infected patients entering into care at the Thomas Street Health Center (Houston, Texas) between February 2007 and January 2009. Eosinophilia was defined as absolute eosinophil count ≥ 400 cells per cubic millimeter. Patients with eosinophilia (cases) at baseline were matched to patients without baseline eosinophilia (controls). Clinical and laboratory data were collected for cases and controls. Variables associated with eosinophilia were evaluated by univariate and multivariate analyses. RESULTS: Sixty-five (9.7%) of 671 ART-naïve patients had eosinophilia. There was no difference in age, sex, race, or baseline CD4 count between patients with and without eosinophilia; however, patients with eosinophilia were more likely to have higher HIV RNA viral loads (5.05 vs 4.82 log10 copies per milliliter; P = 0.019). A total of 52 (80%) of 65 patients with eosinophilia (cases) had at least two follow-up clinic visits. They were matched to 104 controls. Skin rash was the only variable associated with eosinophilia (odds ratio 2.16, 95% confidence interval 1.04-4.47) in our multivariate analysis. Of eight cases tested, only one, from Central America, had a parasitic infection (hookworm). Thirty-eight (73.1%) patients experienced resolution of their eosinophilia by the end of the study (mean follow-up 1019 days). Resolution of eosinophilia did not differ between patients with and without HIV viral suppression. CONCLUSIONS: Eosinophilia is not an infrequent occurrence among ART-naïve HIV-infected patients. Patients with eosinophilia are more likely than patients without eosinophilia to present with a skin rash. HIV RNA viral suppression did not necessarily result in the resolution of eosinophilia. Extensive workup for eosinophilia may not be necessary in most cases.

Measurement issues in using pharmacy records to calculate adherence to antiretroviral drugs.

BACKGROUND: Researchers often use pharmacy records to calculate adherence to antiretrovirals. Variability in the findings may be due to inconsistent methods of calculating adherence. OBJECTIVE: Determine the impact on adherence rates of 6 different calculations that include accounting for whether filled antiretroviral prescriptions were picked up and whether the patient had medications at the start of the observation period. METHODS: Fifty-six patients of a public care system, who had ordered, but failed to pick up, antiretroviral prescriptions from the clinic pharmacy at least once from September thru December, were identified using an electronic pharmacy database. Their adherence during the 4 months was calculated using refilled doses and picked up doses as a percent of prescribed doses. The effect on the calculation of adherence of medications in the patients' possession from August was examined. RESULTS: When medications in the patients' possession from August were considered in calculating adherence, the rate was 54% based on the prescription refill date and 33.4% based on the prescription pick-up date. If medications in the patients' possession at the beginning of the observation period were ignored, adherence based on refill was 48.9% and 28.1% based on pick-up. If the start date for calculating adherence was the date of the first refill or pick-up during the first month of the observation period, adherence rates were 56.2% and 41%, respectively. CONCLUSIONS: This study demonstrated that 6 different methods of calculating adherence from pharmacy records yielded adherence rates of 28.1% to 56.2%. Studies using pharmacy records should specify how adherence is calculated.

Clinical evidence of interaction between itraconazole and nonnucleoside reverse transcriptase inhibitors in HIV-infected patients with disseminated histoplasmosis.

BACKGROUND: Itraconazole is the preferred drug for chronic maintenance therapy in HIV-infected patients with disseminated histoplasmosis. Unfortunately, few clinical data exist confirming a presumed interaction between itraconazole and nonnucleoside reverse transcriptase inhibitors (NNRTIs). OBJECTIVE: To determine whether serum itraconazole concentrations are affected by the type of antiretroviral therapy (NNRTI or protease inhibitor [PI]) being taken concomitantly. METHODS: This retrospective cohort identified patients on antiretroviral therapy and itraconazole for disseminated histoplasmosis between January 2003 and December 2006 at a large HIV clinic in Houston, TX. Available laboratory values were abstracted from medical records. RESULTS: Thirteen itraconazole concentrations from 10 patients were available for analysis: 7 patients were on concomitant PIs, 4 on concomitant NNRTIs, and 2 on antiretroviral regimens containing both PIs and NNRTIs. Six of the itraconazole concentrations during concomitant PI treatment were therapeutic (>1.0 microg/mL), in contrast with none in patients taking an NNRTI. All patients taking concomitant NNRTIs had undetectable serum itraconazole concentrations (<0.05 microg/mL). Two patients switched from NNRTI-based to PI-based antiretroviral regimens and subsequently reached therapeutic itraconazole concentrations. Although limited by small sample size, this study provides the largest clinical data among HIV-infected patients demonstrating that coadministration of an NNRTI and itraconazole results in significant decreases in itraconazole blood concentrations, likely by inducing the CYP3A4 enzyme system. CONCLUSIONS: Itraconazole concentrations should be monitored in patients taking concomitant NNRTIs. PI-based highly active antiretroviral therapy (HAART) may be preferred over NNRTI-based HAART when itraconazole is used to treat HIV-infected patients with disseminated histoplasmosis.

Drug-drug interaction between itraconazole and efavirenz in a patient with AIDS and disseminated histoplasmosis.

Although there is a presumed drug-drug interaction between itraconazole and nonnucleoside reverse-transcriptase inhibitors, the medical literature lacks such documentation. We describe a drug-drug interaction between itraconazole and efavirenz in a patient with disseminated histoplasmosis and acquired immunodeficiency syndrome (AIDS). The drug combination resulted in persistently elevated urinary Histoplasma antigen levels and subtherapeutic plasma itraconazole concentrations. Changing treatment from efavirenz to a protease inhibitor was accompanied by improvements in the desired urinary Histoplasma antigen level and plasma itraconazole concentration.

Brevundimonas diminuta infections and its resistance to fluoroquinolones.

OBJECTIVES: To report infections caused by Brevundimonas diminuta and antibiotic studies of this Gram-negative bacterium. PATIENTS AND METHODS: Seven patients with infection and eight bacterial strains were studied. Tests included antibiotic susceptibility and analysis of the DNA gyrase and topoisomerase genes and the effect of efflux pump inhibitor Phe-Arg-beta-naphthylamide (PANA). RESULTS: The patients all had underlying disease of cancer. The infections involved bloodstream (one case), intravascular catheter (four cases), urinary tract (one case) and pleural space (one case of empyema). Fever up to 39.2 degrees C characterized these infections, which resolved upon treatment by combination antibiotics. Microbiologically, all organisms were resistant to multiple fluoroquinolones and cefepime, but were susceptible to amikacin, imipenem and ticarcillin/clavulanate. These quinolone-resistant B. diminuta strains were probably selected out by the prophylactic use of a quinolone in six of these patients. Additionally, the B. diminuta type strain ATCC 11568(T) that was isolated before the quinolone era from water was also resistant to ciprofloxacin and intermediate to levofloxacin, suggesting intrinsic quinolone resistance. The DNA gyrase and topoisomerase of six analysed strains all contained GyrA Ala-83 and Met-87, GyrB Leu-466 or Thr-466, and ParC Gln-57, Val-66 and Ala-80 that were probably the cause of fluoroquinolone resistance. PANA had nearly negligible effect. CONCLUSIONS: B. diminuta is intrinsically resistant to fluoroquinolones and can be selected out to cause infections.

Efecto del propóleos en la cicatrización de lesiones subcutáneas inducidas en el dorso de ratones: estudio histológico / Effect of the propolis in induced subcutaneous wounds healing in mice: histologic study

Se sabe que el propósito posee características antisépticas, cicatrizantes y anestésicas, razón por la cual es ampliamente utilizado por la población, principalmente para el tratamiento de heridas cutáneas. Considerando lo anteriormente expuesto, nos propusimos analizar histológicamente la acción de la solución de extracto alcohólico del propóleos en heridas, creadas en el dorso de ratones, adonde quedó expuesto el tejido conectivo. Los resultados mostraron que el propóleos no provocó una reacción inflamatoria en el tejido conectivo, promoviendo neo-formación vascular y fibrobástica, induciendo a la formación epiletial. Así, el propóleos puede ser indicado para el tratamiento y reparación por segunda intensión de heridas abiertas en el tejido subcuntáneo

Insuficiencia Venosa Crónica en Atención Primaria: Manejo y derivación

Contiene: anatomía y fisiología venosa, epidemiología y fisiopatología de la IVC, valoración clínica y formas de presentación de la IVC, diagnóstico diferencial en la IVC, tratamiento de la IVC, complicaciones de la IVC, criterios de derivación de la IVC y seguimiento desde AP, puntos clave en la IVC.