Predicting haemorrhage in pre-hospital traumatic patients: evaluation of the novel heart-to-arm time index.

BACKGROUND: Early recognition of hypovolaemia in trauma patients is very important. However, the most often used clinical signs, such as hypotension and tachycardia, lack specificity and sensitivity. METHODS: We propose a non-invasive index of hypovolaemia, the heart to arm time (iHAT), based on a modified pulse transit time indexed to heart rate. Pulse transit time is the sum of pre-ejection period and vascular transit time. Following pre-load reductions due to hypovolaemia, ventricular diastolic filling time increases causing an increase in pre-ejection-period, pulse transit time, and hence iHAT. One hundred and four consecutive patients with suspected major trauma were enrolled. The primary aim was to evaluate the use of the iHAT for detecting haemorrhage in major trauma. The secondary end point was to compare the specificity and sensitivity of iHAT compared to commonly used indexes. RESULTS: iHAT was calculated in 84 subjects, 11 of whom were haemorrhagic. iHAT discriminated haemorrhagic from non-haemorrhagic group (46.8% vs. 66.9%, P < 0.0001). The cut-off for iHAT with the best compromise between sensitivity (90.9%) and specificity (100%) was reached at the 58.78% level. Comparing haemorrhagic and non-haemorrhagic patients, the area under the ROC curve was 0.952 for iHAT, 0.835 for heart rate, and 0.911 for systolic blood pressure, showing no significant differences. CONCLUSIONS: iHAT is a non-invasive index that can identify haemorrhage in trauma patients with high sensitivity and specificity. These data should be considered as an exploration, but any conclusion should be validated in a new set of consecutive patients.

High frequency of non-Hodgkin's lymphoma in patients with HIV-associated Kaposi's sarcoma.

OBJECTIVE: To evaluate, with the support of autopsy findings, the frequency of non-Hodgkin's lymphoma (NHL) among patients with AIDS-associated Kaposi's sarcoma (KS) in comparison with that of AIDS patients with other AIDS-defining diseases. METHODS: The study involved 363 consecutive patients with AIDS who were cared for and died at the Clinic of Infectious Diseases in Milan between May 1984 and December 1992. Clinical records and autopsy data of all of the patients were retrospectively reviewed. Kaplan-Meier product-limit estimates of the time to the development of NHL were calculated for all patients and by specific subgroups. Cox proportional hazards analyses were made to determine the factors associated with the development of NHL. RESULTS: In the majority of cases (82%), KS was diagnosed during life, whereas NHL was diagnosed before death in only 41.6% of cases. Taking the autopsy data into account, the cumulative incidence of the two tumours was 16.8% for KS and 16.5% for NHL. Among the 61 patients in whom KS was the index disease of AIDS, 16 also developed NHL. The probability of developing NHL was significantly higher in patients with KS at AIDS diagnosis than in patients with Pneumocystis carinii pneumonia (PCP), oesophageal candidiasis or other AIDS-related diseases (P = 0.004). Multivariate analysis of the factors associated with the development of NHL (such as sex, age, risk factors, AIDS-defining diseases and CD4+ cell counts) showed that the patients with KS as the index disease of AIDS had a 5.3-fold higher risk of developing NHL than the patients with PCP as the primary manifestation of AIDS. CONCLUSIONS: Our results confirm the higher incidence of malignant lymphoma in patients with AIDS-KS than in patients with other AIDS-related diseases. The importance of autopsy in assessing these data is underlined by the high percentage of NHL diagnosed only after death. These observations may support the hypothesis of a common aetiological agent, or of a common pathway, for the two neoplasms.

Redistribution of body fat in HIV-infected women undergoing combined antiretroviral therapy.

OBJECTIVES: To investigate the prevalence, metabolic features and risk factors of a particular pattern of fat redistribution (FR), characterized by a progressive enlargement of breast and abdominal girth associated with a wasting of the lower limbs, observed in HIV-infected women treated with combined antiretroviral (ARV) therapy. DESIGN: Cross-sectional study. SETTING: Outpatients attending the Institute of Infectious Diseases, University of Milan, Milan, Italy. PATIENTS AND METHODS: HIV-infected women treated with two or more ARV drugs, observed between December 1997 and February 1998. FR was confirmed by means of a physical examination and dual-energy X-ray absorptiometry (DEXA). The metabolic and endocrinological measurements in patients with FR were compared with those in FR-free women. RESULTS: FR was observed in 32 out of 306 women (10.5%). DEXA revealed more trunk fat (P < 0.01) and less leg fat (P < 0.001) in the patients with FR than in the matched controls. There were no significant differences in laboratory test results between the two groups. All of the FR patients were taking lamivudine-containing regimens; 20 of them were also taking a protease inhibitor (PI). The association of FR with lamivudine-including regimens was statistically significant (P = 0.017). Among the patients taking lamivudine, the risk associated with treatments including PI was 1.8 (95% CI 0.8-3.8, P = 0.12). A total duration of ARV therapy of more than 1000 days was associated with a greater risk of developing FR (OR 10.8; 95% CI 1.4-80.5; P = 0.0207). Stepwise logistic regression analyses indicated that prolonged ARV therapy and a viral load of more than 10000 copies per ml at the beginning of the last ARV regimen were the only variables that significantly and independently correlated with the risk of FR. CONCLUSIONS: The observed body modifications are caused by a redistribution of body fat without fat loss that is apparently not associated with hyperlipidemia, altered glucose metabolism or other endocrinological disorders. The development of FR in patients receiving only reverse transcriptase (RT) inhibitors suggests the presence of a PI-independent mechanism that deserves further investigation.

Lack of in vitro anti-gp160 antibody production is a correlate of nonprogression among HIV type 1-infected individuals.

The aim of our study was to investigate the possible correlation of in vitro antibody production (IVAP) directed to the gp160 protein of HIV-1 with CD4+ slopes, plasma viremia, and disease progression in long-term nonprogressors (LTNPs). Nineteen subjects with a long-term nonprogressive HIV-1 infection were studied and followed for 2 years. During the follow-up, in vitro anti-gp160 producers showed negative CD4+ slopes in the majority of cases (9 of 12), whereas 5 of 7 nonproducers showed positive CD4+ slopes. Plasma viremia values, which were not significantly different in the two groups at baseline, became significantly higher in anti-gp160 producers when compared with nonproducers during the follow-up (p = 0.012). Finally, a trend toward progression was observed in the group of producers but not in nonproducers. These findings suggest that the in vitro production of anti-gp160 antibodies by peripheral B cells is not a correlate of protection, and may represent an early predictor of progression in LTNPs.

High prevalence of false-negative anti-HTLV type I/II enzyme-linked immunosorbent assay results in HIV type 1-positive patients.

A high frequency of false-negative anti-HTLV-I/II ELISA results has been reported by several authors. To verify the possible underestimate of the prevalence of HTLV-II infection in subjects infected by HIV-1, we used the PCR to investigate the presence of HTLV DNA in peripheral blood mononuclear cells (PBMCs) collected from a group of 67 HIV-1-positive anti-HTLV-I/II ELISA-negative individuals; the study population included 31 patients with HIV-1-related peripheral neuropathy (PN), 15 with non-Hodgkin lymphoma (NHL), and 23 without PN or NHL. Two subjects had both PN and NHL. All of the patients who were positive at PCR were investigated for the presence of serum anti-HTLV-I/II antibodies by means of Western blot (WB). Eighteen (26.9%) of the 67 anti-HTLV-I/II ELISA-negative patients had HTLV DNA in their PBMCs and WB-detectable serum antibodies directed against one or more HTLV antigens. The individuals affected by predominantly sensory polyneuropathy (PSP) had a significantly higher prevalence of HTLV DNA than the others. All of the patients in whom HTLV-I/HTLV-II discrimination was successful had HTLV-II, with the exception of one patient who was infected by HTLV-I. The present study confirms the possibility of HTLV infection in the absence of ELISA-detectable serum anti-HTLV-I/II antibodies, especially in the particular setting of HIV-1-infected individuals. Moreover, the fact that the prevalence of HTLV DNA was significantly higher in the subjects affected by predominantly sensory polyneuropathy further supports the possibility of an association between HIV-1-related PSP and HTLV-II.

Post-kala-azar dermal leishmaniasis during highly active antiretroviral therapy in an AIDS patient infected with Leishmania infantum.

We report a case of post-kala-azar dermal leishmaniasis (PKDL) in a woman with AIDS which occurred 13 months after a diagnosis of visceral leishmaniasis concomitantly with immunological recovery induced by highly active retroviral therapy. Cytokine pattern at the time of visceral leishmaniasis and PKDL diagnosis was studied and pathogenic implications were discussed.

[Metabolic alkalosis. Compensation mechanisms in the light of new experimental data]. / In tema di alcalosi metabolica. Il problema dei meccanismi di compenso alla luce di muovi dati sperimentali

Changes in arterial blood and erythrocyte acid-base and electrolyte balance in the course of acute alkalinisation caused by bicarbonate loading showed that extracellular alkalosis has no significant effect on the concentration of intraerythrocyte bicarbonate concentration, though a marked increase in pH and electrolyte balance within the red cell is apparent. Erythrocyte alkalinisation may thus be seen as essentially due to the escape of H+ ions, while the entry of Na+ ions is the main device by which the law of electroneutrality is respected. The literature suggests that lactic acid offers a source of H+ ions for destruction of bicarbonate, whereas the diffusion of the ion lactate within the cell is compensated by the release of Cl-. In addition, the data now reported indicate that the red cell is a sufficiently valid model for the study of phenomena occurring within the intracellular compartment when a state of extracellular alkalinisation in created.

[Metabolic alkalosis. Relation between bicarbonate load and the behavior of blood lactic acid in the light of the intra-erythrocyte indices of the acid-base balance]. / In tema di alcalosi metabolica. I rapporti fra carico di bicarbonato ed andamento della lattacidemia alla luce degli indici intraeritrocitari dell'equilibrio acido-base

The plasma an intra-erythrocyte acid-base balance in man was studied, along with blood pyruvate and lactate levels, in acute metabolic alkalosis induced by i.v. infusion of bicarbonate. It was found that the red cell offers a satisfactory expression of the phenomena that occur in the intracellular space. The bicarbonate ion has difficulty in crossing the red cell membrane, while the production of lactate is seen as a fundamental compensation mechanism for rapid buffering of the extra base.

[Metabolic alkalosis. III. Spontaneous and experimental compensation mechanisms in plasma and erythrocytes]. / In tema di alcalosi metabolica. Nota III.--Studio, nel plasma e nell'eritrocito, dei meccanismi di compenso spontanei e sperimentali.

Plasma and red cell acid-base balance were studied in 13 patients with metabolic alkalosis and 14 healthy subjects following the infusion of bicarbonate. Differences between the plasma and red cell patterns suggested that application of the results of plasma determinations to the body as a whole could be the cause of serious inaccuracies. Since the changes noted occurred in different combinations according to whether alkalinisation was acute or not, it is felt that cell response to a fall in (H+) varies in relation to the time available for compensation.

[Ocular complications in patients undergoing long-term hemodialysis and renal transplants from cadavers]. / Le complicanze oculari nel paziente sottoposto ad emodialisi cronica e trapianto renale da cadavere.

In 36 subjects in chronic hemodialysis treatment and in 36 patients with a renal transplant, well functioning for more than one year, the ocular complications related to the specific form of treatment were evaluated and compared. In the group of the dialyzed subjects ocular pathology was composed by: lens opacities in 9 cases, corneal calcifications in 7 cases, hypertensive fundus in 8 cases. In no patient these lesions produced measurable visus reductions. In the transplant group ocular pathology was composed by: lens opacities in 28 patients, hypertensive fundus in 7 and intraocular hypertension in one. One case of herpes cheratytis and one case of endophtalmytis have also been observed. In 9 patients these lesions produced a remarkable visus reduction. In conclusion renal transplantation shows a greater incidence of ocular complications if compared to hemodialysis. This situation has not important consequences on the rehabilitation of the transplanted subject for the possibility of surgical correction of the cataract.

[Disseminated histoplasmosis in patients with AIDS. 2 case reports]. / Istoplasmosi disseminata in pazienti affetti da AIDS. Descrizione di due casi.

Histoplasmosis is endemic in some areas of United States and in South America, and generally causes an acute self-limiting respiratory infection. In elderly and immunosuppressed patients the infection can spread through the blood, causing a severe systemic illness. Here we describe two cases of disseminated histoplasmosis in AIDS patients. The first was observed in an Italian woman who had never visited endemic countries, and was recognized only at autopsy; the second was observed in a trans-sexual patient, arrived in Italy from Brazil. Clinical suspicion of histoplasmosis is important in immunocompromised patients of non-endemic areas as symptoms are often aspecific and misdiagnosis is frequent.