Are multiple-use bottles of chlorhexidine solutions at risk of contamination in joint replacement surgery?

INTRODUCTION: Chlorhexidine gluconate 2% w/v in isopropanol 70% solutions in multiple-use bottles is commonly used in surgery as a cost-effective method for skin disinfection. However, multiple-use bottles risk contamination. This study aims to test whether bacterial contamination of multiple-use bottles or their solutions occurs once open and on use between different patients. METHODS: Consecutive samples were taken each time a chlorhexidine bottle was used over a 7-day study period. Samples were tested using blood culture, agar plate and mass spectrometry. RESULTS: No growth was observed in 52 samples taken from 18 bottles inoculated into blood culture bottles. Four growths on agar plate culture were determined to be contaminants from the sampling process. CONCLUSIONS: This study supports the use of multiple-use bottled chlorhexidine solutions as safe and cost-effective in surgical practice.

Human immunodeficiency virus atropy induces modification of subcutaneous adipose tissue architecture: in vivo visualization by high-resolution magnetic resonance imaging.

BACKGROUND: Human immunodeficiency virus (HIV) infection generally induces lipodystrophy. For targeted treatment a better understanding of its development is necessary. The utility of high-resolution magnetic resonance imaging (MRI) is explored. OBJECTIVES: The present study presents a way to visualize the adipose tissue architecture in vivo and to inspect modifications associated with the atrophy. METHODS: High-resolution MRI scans with surface coils were performed on the calf and at the lumbar region of three groups of patients: HIV patients with lipoatrophy, HIV patients without lipoatrophy and healthy volunteers. All patients underwent a clinical examination. In addition, dual energy X-ray absorptiometry (DEXA) measurements were taken. On the MRI scans adipose tissue thickness and adipose nodule size were measured. Results High-resolution MRI enabled identification of a clear disorganization of adipose tissue in patients with lipoatrophy. In addition, these patients presented a very small adipose tissue thickness on the calf and a very small nodule size. RESULTS: led to the hypothesis that adipose tissue disorganization appears before changes in DEXA measurements or clinically visible modifications. CONCLUSIONS: High-resolution MRI enabled visualization in vivo of precise changes in tissue organization due to HIV lipoatrophy. This imaging technique should be very informative for better monitoring of the atrophy.

Imiquimod 5% cream for external genital or perianal warts in human immunodeficiency virus-positive patients treated with highly active antiretroviral therapy: an open-label, noncomparative study.

BACKGROUND: Human immunodeficiency virus (HIV)+ patients have an increased risk of anogenital warts. High-risk (HR) human papillomaviruses (HPVs), especially types 16 and 18, are major risk factors for precancerous and cancerous lesions of the anogenital tract, while low-risk (LR) HPVs are associated with benign lesions. Cure of genital warts with ablative techniques, surgical excision, podophyllotoxin or trichloroacetic acid is frequently difficult. Treatment with imiquimod cream showed a total clearance of external genital or perianal warts in about 50% of immunocompetent subjects. However, total clearance was reduced in HIV+ subjects not treated with highly active antiretroviral therapy (HAART). OBJECTIVES: To assess clinically and by monitoring HPV content the efficacy of 5% topical imiquimod to treat anogenital warts in HIV+ subjects with at least partially restored immune functions. METHODS: Fifty HIV+ patients successfully treated with HAART (total CD4+ cells > or = 200 cells mm(-3) and plasma HIV RNA load < 10(4) copies mL(-1)) with anogenital warts were included. Imiquimod 5% cream was applied on external genital or perianal warts three times weekly for up to 16 weeks. Warts were tested at entry and after treatment for human LR- and HR-HPV DNA. RESULTS: Total wart clearance was observed in 16 of 50 (32%) patients at week 16. At enrolment, HPV DNA was present in more than 90% of lesions with a majority of lesions co-infected by HR- and LR-HPV. At study end, the HPV load decreased or became undetectable in 40% of cases studied. CONCLUSIONS: Imiquimod 5% cream did not show safety concerns and is suitable for use in HIV+ subjects with anogenital warts and successful HAART treatment.

Impact of HIV infection on total body composition in treatment-naive men evaluated by dual-energy X-ray absorptiometry comparison of 90 untreated HIV-infected men to 241 controls.

The aim of this study was to establish the contribution of human immunodeficiency virus (HIV) itself on body composition changes evaluated by dual-energy X-ray absorptiometry (DXA). Body composition evaluated by DXA in 90 HIV never treated men, without comorbidity, or current or past opportunistic infections were compared with 241 healthy volunteers. The mean duration of seropositivity from HIV diagnosis was 41+/-62 mo, mean CD4 and viral load at the time of DXA were 402/mm(3)+/-263 (control values 500-1200/mm(3)) and 4.2 log copies/mL+/-1.3. Mean age (41 vs 39 yr, respectively, for HIV never treated patients and controls) and mean height (174.5 vs 176 cm) were not different, but mean weight was lower among HIV never treated patients (69.8 vs 78.7 kg). Mean total body bone mineral density (BMD) of naive HIV-infected patients was lower than that of controls (1.20 vs 1.23 g/cm(2), p=0.01) but not after adjustment on age, height, lean mass (LM), and fat mass ratio (FMR=% trunk fat mass/% lower limb fat mass). Fat mass (13.2 vs 16.5 kg, p<0.0001) and LM (53.5 vs 59 kg, p<0.0001) of naive HIV-infected patients were lower whatever the adjustment variables. The FMR was lower in naive HIV-infected men (1.0 vs 1.3, p<0.0001) because of a decreased trunk fat mass. After adjustment on age, height, LM, and fat mass, the lower limbs fat mass percentage was higher in HIV-infected men. The profile of naïve HIV-infected patients displayed low lean and fat masses, and a fat mass repartition characterized by a predominant loss in the trunk. Those alterations may result from the catabolic effect of the chronic HIV infection.

Total body composition by DXA of 241 HIV-negative men and 162 HIV-infected men: proposal of reference values for defining lipodystrophy.

The aim of this study was to define standard values for fat mass distribution by dual-energy X-ray absorptiometry in human immunodeficiency virus (HIV)-negative men and to analyze factors associated with lipodystrophy in HIV-infected men. Total-body composition was analyzed in 241 HIV-negative men (controls) and 162 HIV-infected men. We created a fat mass ratio (FMR) as the ratio of the percentage of the trunk fat mass to the percentage of the lower limbs fat mass. We defined the FMR standard values as the mean value+/-standard deviation. We compared body mass index (BMI), fat mass percentage (%FM), lean mass (LM), bone mineral density (BMD), and FMR between the control group and HIV-infected men, by age range, according to prescription of treatment and presence of clinical lipodystrophy. The FMR standard value is equal to 1.3+/-0.2. The FMR was higher in treated HIV-infected men with or without clinical lipodystrophy. The FMR was similar for naïve HIV-infected men and controls. It was positively correlated with age, cumulative time on treatment, zidovudine, stavudine, or indinavir. BMD and fat mass were lower for treated and naïve HIV-infected men than for HIV-negative men. The FMR seems to be a valuable index for measuring fat mass distribution. We defined FMR standard values from the largest group of HIV-negative men to our knowledge. Applying FMR to HIV patients could help physicians to diagnose lipodystrophy earlier.

Acute generalized exanthematous pustulosis: a cutaneous adverse effect due to prophylactic antiviral therapy with protease inhibitor.

We describe a human immunodeficiency virus-seronegative man who presented with a skin disorder that we diagnosed as acute generalized exanthematous pustulosis, which we believe was an adverse reaction to combination prophylactic therapy with zidovudine, lamivudine, and protease inhibitor for human immunodeficiency virus. Cutaneous adverse effects are rarely reported with the use of these antiviral drugs.

Indinavir-associated lipodystrophy.

BACKGROUND: Lipodystrophies are rare cutaneous disorders characterized by the symmetrical loss of subcutaneous fat from the body surface. The cause of lipodystrophy is not known, but a possible genetic predisposition is likely and either overt diabetes mellitus or insulin resistance are often associated. DESIGN AND METHODS: Case study. PATIENTS: Eight patients who developed either partial or generalized lipodystrophy after protease inhibitor therapy. RESULTS: In all eight patients lipodystrophy occurred after 2-12 months of starting indinavir and was not preceded by weight loss or inflammatory skin disease. Short-term follow-up after withdrawal of therapy showed no change in the patients' appearance. One patient developed glycosuria as lipodystrophy became manifest. In three cases glucose tolerance test was performed revealing a high level of insulin between the first and third hour of loading. CONCLUSIONS: In our view, lipodystrophy is an unwanted side-effect of protease inhibitor therapy causing noticeable disfigurement.

Gynaecomastia in a male patient during stavudine and didanosine treatment for HIV infection.

We report a case of gynaecomastia developed in a HIV-seropositive man, associated with a severe lipodystrophy. We hypothesize the responsibility of stavudine and didanosine in the development of these 2 complications. If many reports suggest that the protease inhibitors may promote gynaecomastia, long-term nucleoside analogue therapy may also cause this side effect.

[Rupture of the distal thoracic esophagus by closed trauma]. / Rupture de l'oesophage thoracique distal par traumatisme fermé.

Closed traumatic rupture of the esophagus is uncommon, usually located in the upper third of the esophagus. We report a case occurring in the lower third. This diagnosis must be envisaged when faced with delayed clinical and radiological signs. The prognosis is severe and the therapeutic decisions are controversial.

[Pseudo-hypertrophic pelvi-crural amyloid myopathy in lambda light-chain myeloma. Clinical, morphological and immunocytochemical study]. / Myopathie amyloide pelvicrurale pseudo-hypertrophique au cours d'un myélome a chaines légères lambda. Etude clinique, morphologique et immunocytochimique.

The case of 65 year old woman with progressive enlargement and "wooden" induration of the pelvic girdle and thigh muscles due to an amyloid infiltration is reported. Muscle changes appeared two years after a diagnosis of myeloma with free lambda light chains. The patient complained of muscle pain, lassitude and weakness. Macroglossia was present. Skeletal muscle (vastus lateralis) contained large amounts of amyloid substance and showed type 2B atrophy. There was no fiber type grouping. Some amyloid deposits abutted on the muscle fiber, destroyed the basal lamina and sarcolemma, but never infiltrated it. Besides the amyloid phagocytosis by macrophages, a relationship between amyloid filaments and fibroblasts was present. Another non-congophilic substance was revealed using the Avidin-Biotin peroxidase complex to localize lambda light chains by light microscopy and corresponded to a granular substance in electron microscopy. Clinicopathological results are discussed with a review of thirteen similar cases previously reported.

Violence by psychiatric in-patients.

A review of studies on violence by psychiatric in-patients is presented. Violence in various settings has been studied and a few general conclusions emerge. The assailant is commonly a young schizophrenic. Only few patients are repeatedly violent. Persistently violent schizophrenics have been shown to have neurological impairments. Violence usually occurs in crowded, unstructured settings. There is no agreed definition of assaults and how they should be graded. Although violence is common it rarely leads to serious physical consequences. Victims are most often nursing staff. Some staff and patients are assaulted more often than others. Violence is difficult to predict. Ways of preventing assaultive behaviour are discussed. After considering some problems with existing studies, areas for further study are suggested.

[Lupus erythematosus and papules. 4 cases]. / Lupus érythémateux et papules: Quatre observations.

Papular skin eruptions are uncommon in lupus erythematosus (LE), and their occurrence may suggest several diagnoses. We report four cases of papular eruptions in LE patients. Two of these patients had purely lupoid papules on acute LE in one and on chronic LE in the other. In the remaining two cases the papules were formed by mucinous deposits that were either secondary to LE or belonged to an associated primary mucinosis. These four cases prompted us to discuss the significance of papular eruptions in lupus erythematosus. LE-specific papular manifestations have a purely lupoid histological and immunopathological substratum. In systemic LE, the frequency of these manifestations varies from one series to another, but they seem to rank fourth after vespertilio, alopecia and photosensitivity. The papules vary in size and number, and they usually complicate a severe and active systemic LE. In chronic LE, a papulo-nodular eruption may be observed, but this is even rarer. Papules occurring in the course of LE may suggest a diagnosis of mucinosis, this disease being either secondary to, or associated with LE. Secondary mucinosis is intricated with LE-specific histological abnormalities. It appears as a symptomatic alcianophilic deposit induced by cytological alterations in some dysimmune collagen diseases, such as dermatomyositis or LE. In the literature, three cases of mucinosis secondary to LE are well documented, and to these we add a fourth case in which the papules contained lupoid lesions and a variable amount of dermal mucinous deposit. The literature has also yielded sixteen cases of primary papular mucinosis associated with systemic LE (12 cases) or chronic LE (4 cases); we add to these a case of systemic LE in which the papular eruptions varied in course, density and size of the papules. As in isolated papular mucinosis, histology regularly shows a copious mucinous deposit. When present, the LE-specific skin manifestations are clearly distinct from those of mucinosis (except for the above-mentioned cases of papular lupus). The course of papular mucinosis usually runs parallel to that of LE which is characterized by its severity and its articular, haematological and renal manifestations. Analysis of the literature also provides various anatomico-clinical elements which help in differentiating between isolated papular mucinosis and primary papular mucinosis associated with LE. In the majority of cases treatment relies on corticosteroid therapy or synthetic antimalarial agents, but the results are irregular since LE seems to be more resistant to treatment than mucinosis.(ABSTRACT TRUNCATED AT 400 WORDS)

Domiciliary clinics I: effects on non-attendance.

OBJECTIVE: To compare the rate of non-attendance for new referrals to a hospital based clinic versus home assessment. SETTING: Two old age psychiatry services in an urban area. METHOD: A four year prospective study comparing rates of non-attendance for new referrals to a hospital based clinic versus assessment at home in two parallel old age psychiatry services. RESULTS: The rate of non-attendance for new referrals seen at home was considerably lower (1.7%) than the hospital based clinic (21.2%). CONCLUSIONS: Assessing new outpatient referrals to old age psychiatry services at home reduces non-attendance. This improves efficient use of medical time in a small geographical catchment area but may not apply to rural or larger areas.

Ivermectin-responsive Demodex infestation during human immunodeficiency virus infection. A case report and literature review.

We report the case of a 56-year-old HIV-seropositive man who presented a facial Demodex infection developed 2 months after initiation of highly active antiretroviral therapy. The Demodex infection was confirmed by scrapings and histopathologic examination and by the dramatic response to antiparasitic treatment with oral ivermectin associated with 5% permethrin cream.

Electron-beam therapy in Arndt-Gottron's scleromyxoedema.

We report a patient with Arndt-Gottron's scleromyxoedema whose skin lesions responded to electron-beam therapy. This treatment appears to be effective in improving the cutaneous signs and functional impairment of this disease.

Focal epithelial hyperplasia (Heck disease) associated with AIDS.

Focal epithelial hyperplasia (FEH) of the oral mucosa occurring in a HIV-infected man is described. Molecular biology disclosed an HPV-32 type in oral lesions. The association of FEH and AIDS is uncommon although many HPV subtypes may manifest during HIV infection.

Cutaneous non-epidermotropic lymphoma associated with human immunodeficiency virus infection.

A case of pure non-epidermotropic cutaneous lymphoma in a human immunodeficiency virus-infected patient is reported following a viral opportunistic infection [cytomegalovirus (CMV) hepatitis]. The lymphoid infiltrate was Epstein-Barr virus and CMV negative with a CD30-positive T-cell phenotype. Molecular analysis demonstrated T cell receptor gene rearrangement, but a non-aggressive disease course was noted supporting a cautious therapeutic approach in this case.