HIV or HIV-therapy? Causal attributions of symptoms and their impact on treatment decisions among women and men with HIV.

OBJECTIVES: Among people with HIV, we examined symptom attribution to HIV or HIV-therapy, awareness of potential side effects and discontinuation of treatment, as well as sex/gender differences. METHODS: HIV-patients (N=168, 46% female) completed a comprehensive symptom checklist (attributing each endorsed symptom to HIV, HIV-therapy, or other causes), reported reasons for treatment discontinuations and potential ART-related laboratory abnormalities. RESULTS: Main symptom areas were fatigue/sleep/energy, depression/mood, lipodystrophy, and gastrointestinal, dermatological, and neurological problems. Top HIV-attributed symptoms were lack of stamina/energy in both genders, night sweats, depression, mood swings in women; and fatigue, lethargy, difficulties concentrating in men. Women attributed symptoms less frequently to HIV than men, particularly fatigue (p<.01). Top treatment-attributed symptoms were lipodystrophy and gastrointestinal problems in both genders. Symptom attribution to HIV-therapy did not differ between genders. Over the past six months, 22% switched/interrupted ART due to side effects. In women, side effect-related treatment decisions were more complex, involving more side effects and substances. Remarkably, women took predominantly protease inhibitor-sparing regimens (p=.05). Both genders reported only 15% of potential ART-related laboratory abnormalities but more than 50% had laboratory abnormalities. Notably, women had fewer elevated renal parameters (p<.01). CONCLUSIONS: Men may attribute symptoms more often to HIV and maintain a treatment-regimen despite side effects, whereas women may be more prudent in avoiding treatment side effects. Lacking awareness of laboratory abnormalities in both genders potentially indicates gaps in physician-patient communication. Gender differences in causal attributions of symptoms/side effects may influence treatment decisions.

Treatment during primary HIV infection does not lower viral set point but improves CD4 lymphocytes in an observational cohort.

OBJECTIVE: To investigate if early treatment of primary HIV-1 infection (PHI) reduces viral set point and/or increases CD4 lymphocytes. METHODS: Analysis of two prospective multi-centre PHI cohorts. HIV-1 RNA and CD4 lymphocytes in patients with transient treatment were compared to those in untreated patients. Time to CD4 lymphocyte decrease below 350/ microl after treatment stop or seroconversion was calculated using Kaplan-Meier and Cox-PH-regression analyses. RESULTS: 156 cases of PHI were included, of which 100 had received transient HAART (median treatment time 9.5 months) and 56 remained untreated. Median viral load (563000 cop/ml vs 240000 cop/ml; p<0.001) and median CD4 lymphocyte (449/ microl vs. 613/ microl; p<0.01) differed significantly between treated and untreated patients. Median viral load was 38056 copies/ml in treated patients (12 months after treatment stop) and 52880 copies/ml in untreated patients (12 months after seroconversion; ns). Median CD4 lymphocyte change was +60/ microl vs. -86/ microl (p = 0.01). Median time until CD4 lymphocytes decreased to <350/ microl (including all patients with CD4 lymphocytes <500/ microl during seroconversion) was 20.7 months in treated patients after treatment stop and 8.3 months in untreated patents after seroconversion (p<0.01). Cox-PH analyses adjusting for baseline VL, CD4 lymphocytes, stage of early infection and symptoms confirmed these differences. CONCLUSIONS: Treatment during PHI did not lower viral set point. However, patients treated during seroconversion had an increase in CD4 lymphocytes, whereas untreated patients experienced a decrease in CD4 lymphocytes. Time until reaching CD4 lymphocytes <350/ microl was significantly shorter in untreated than in treated patients including patients with CD4 lymphocytes <500/ microl during seroconversion.

International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study.

BACKGROUND: A wide range of physical tests have been published for use in the assessment of musculoskeletal dysfunction in patients with headache. Which tests are used depends on a physiotherapist's clinical and scientific background as there is little guidance on the most clinically useful tests. OBJECTIVES: To identify which physical examination tests international experts in physiotherapy consider the most clinically useful for the assessment of patients with headache. DESIGN/METHODS: Delphi survey with pre-specified procedures based on a systematic search of the literature for physical examination tests proposed for the assessment of musculoskeletal dysfunction in patients with headache. RESULTS: Seventeen experts completed all three rounds of the survey. Fifteen tests were included in round one with eleven additional tests suggested by the experts. Finally eleven physical examination tests were considered clinically useful: manual joint palpation, the cranio-cervical flexion test, the cervical flexion-rotation test, active range of cervical movement, head forward position, trigger point palpation, muscle tests of the shoulder girdle, passive physiological intervertebral movements, reproduction and resolution of headache symptoms, screening of the thoracic spine, and combined movement tests. CONCLUSIONS: Eleven tests are suggested as a minimum standard for the physical examination of musculoskeletal dysfunctions in patients with headache.

Cartilaginous metaplasia in calcific aortic valve disease.

In a 49-year-old man, symptoms of aortic valve stenosis developed that required surgical intervention with valve replacement. Pathologic examination of the valve showed severe calcific aortic sclerosis and foci of hyaline cartilage. The authors believe that these foci are secondary to cartilaginous transformation of mesenchymal valvular tissue. This represents abnormal repair of valvular tissue damaged, in this case, by the nodular calcific process of calcific aortic stenosis.

Renal oncocytoma followed for eighteen years without resection.

The natural history of unresected renal oncocytomas is unknown. We report a renal oncocytoma which was mistakenly diagnosed as benign renal cyst and followed up for eighteen years. We are unable to find other oncocytomas without resection which were followed up. The apparent lack of change in size over eighteen years supports the concept of slow growth. Malignant histologic characteristics confirm the potential for malignant degeneration in what is generally considered to be a benign lesion.

Skin hypersensitivity tests in buffaloes parasitized with Toxocara vitulorum.

Skin tests were done using larval extract and excretory-secretory (ES) antigens injected intradermally in the neck area of 30, 11- to 200-day-old buffalo calves and nine 27- to 100-day postparturition buffalo cows. The skin of the buffaloes infected with Toxocara vitulorum, mainly calves, demonstrated a hypersensitive response to antigens, especially to the larval extract antigens. Skin hypersensitivity responses were characterized by the presence of dermal nodules with progressive induration and an increase of up to four times the size of the original area at 30 min (immediate type) and at 72 h (delayed type) after injection. Histological preparations of skin reactions at 72 h showed a typical mononuclear cell infiltration, with eosinophils and perivascular cuffing in most of the animals. Fecal examination of 75 animals showed that 65 (86.7%) buffalo calves (9-115 days old) were parasitized with T. vitulorum. The peak of egg output from these animals occurred when they were approximately 45 days old.

Ileal mucosal mast cell, eosinophil, and goblet cell populations during Hymenolepis diminuta infection of the rat.

The population dynamics in the enteric connective tissues of eosinophils, mucosal mast cells (MMC), and in the mucosal epithelium of goblet cells were examined morphometrically in fixed ileal tissue of outbred Sprague Dawley rats during the first 32 days of infection with the tapeworm Hymenolepis diminuta. MMC and eosinophils were present in the lamina propria and submucosa; however, only eosinophils were also present in the muscularis externa. Eosinophilic infiltrate was first observed in the lamina propria at 15 days postinfection (dpi) and the numbers of eosinophils remained elevated through 32 dpi. Initial mucosal mastocytosis was detected on 6 dpi and MMC numbers continued to rise over the study period without reaching a plateau. Goblet cell hyperplasia occurred only at 32 dpi. In contrast to some intestinal nematode infections where these same 3 cell types are associated with the host's expulsion responses, H. diminuta is not lost by a rapid host response in the outbred Sprague Dawley rat strain used in these experiments. We suggest that either the induction of hyperplasia of these host effector cells in ileum tissue during H. diminuta infection is not capable of triggering parasite rejection mechanisms, or the function of the induced hyperplasia is necessary for some as yet unassociated physiological or tissue architecture change in the host's intestine.

[Anatomic variants as a rare cause of distal ulnar nerve compression]. / Anatomische Variante als seltene Ursache einer distalen Ulnariskompression.

A case of anatomical variation of the course and branching of the ulnar nerve causing a nerve compression syndrome at the wrist joint is described. Decompression and transposition as well as tenotomy of the flexor carpi ulnaris were carried out, followed by improvement in neurological findings and complaints.

[Isolated fractures of the shoulder blade in childhood and adolescence]. / Isolierte Frakturen des Schulterblattes im Kindes- und Jugendalter.

Fractures of the scapula in childhood and youth are very rare injuries. Despite the few number of cases one can clearly distinguish, with regard to the cause of the accident, the sort of forces involved and the type of fracture, between those injuries received by adults and those of children. In the case of children and youths isolated scapular injuries and a larger number of isolated fractures of the acromial and the coracoid processes can be found. For an accurate diagnosis a thorough radiological examination must be undertaken, and if necessary further special x-ray projections or on-target x-ray spot exposures.

[Differential diagnosis of skull fracture in childhood]. / Zur Differentialdiagnose der Schädelfraktur im Kindesalter.

Premature development of the diploic veins in babyhood or early infancy is rare. Differential diagnosis of fracture is difficult especially in unilateral findings. The author presents a case of a 2 5/12 year-old infant with an unilateral frontal diploic vein.

[Migration of Kirschner's wire after osteosyntheses (author's transl)]. / Kirschnerdrahtwanderung nach Osteosynthesen.

The article reports on four cases of migration of Kirschner's wire after osteosyntheses at the shoulder girdle and forearm. In two patients, the wire travelled into the musculature of the neck or throat, whereas in another case the dislocated wire was in transdiaphragmal position, partly intrathoracically and partly intrahepatically. In each case, removal of the implants resulted in complication-free healing. The article gives general guidelines for treatment in order to avoid wire migration in osteosyntheses using Kirschner's wire.

[Ossifications of soft parts after operative treatment of luxation fractures of the ankle joint (author's transl)]. / Weichteilverknöcherungen nach operativer Versorgung von Verrenkungsbrüchen des oberen Sprunggelenkes.

Operative treatment of luxation fractures of the ankle joint has caused a drop in poor late results, to one-quarter of the total number of patients compared with about one-half with the conservative procedure. Part of the unsatisfactory results is caused by ossifications in region of the interosseous membrane and tibiofibular syndesmoses. The incidence of such ossifications within a closed series of 200 own operatively treated cases was examined and pathogenetic factors were discussed. Further improvement of the treatment results of ankle joint fractures appears possible via subtle operation technique and omission of routine application of fixation screws for safeguarding lesions of the syndesmoses.

[Isolated and combined abdominal traumas (author's transl)]. / Isolierte und kombinierte Bauchverletzungen.

A group of 89 patients treated for abdominal traumas between 1975 and 1980 is analyzed in respect of type and cause of accident, concomitant traumas and intra-abdominal organ lesion patterns. Isolated abdominal traumas are compared with abdominal traumas within an overall polytrauma. Complications and causes of death among the authors' own patients are reported. The relatively high overall mortality rate of 38% is due to the above-average proportion of multiple traumas amounting to 72%. Multiple intra-abdominal injuries or organs, simultaneous involvement of the thorax and necessary massive transfusions result in particularly unfavourable prognoses.

[Results of surgically treated luxation fractures of the upper ankle joint (author's transl)]. / Ergebnisse operativ versorgter Verrenkungsbrüche des oberen Sprunggelenkes.

113 patients were followed up after an average period of 27.2 months postoperatively following surgical treatment of luxation fractures of the ankle joint, from a closed series of 200 operations carried out in accordance with AO principles. Unsatisfactory late results were found in Type C in 38.6% of the cases, in the total group in 29.2% of the cases. The rate of infection was about 2%. One-third of the poor results were due to pre-arthrotic deformities or damages due to accidents; over and above this, surgico-technical complications led to unsatisfactory treatment results.