HIV-associated neurocognitive disorders (HAND).

Neurocognitive impairment still occurs in the era of HAART, though its onset appears to be delayed and its severity reduced, while HIV-infected individuals live longer with the infection. HAND defines three categories of disorders according to standardized measures of dysfunction: asymptomatic neurocognitive impairment (ANI), mild neurocognitive disorder (MND), and HIV-associated dementia (HAD). The pathogenic mechanisms underlying HAND involve host and virus characterizations and interactions and seem to depend heavily on the overall condition of the immune system. Since there are insufficient data at this point to determine the best therapeutic approach, and since HAART apparently is not sufficient to prevent or reverse HAND, therapy with a combination of drugs with high CPE should be considered while adjunctive and alternative therapies are being explored.

A cost-effective method for reducing the volume of laboratory tests in a university-associated teaching hospital.

BACKGROUND: Laboratory tests comprise a significant portion of hospital expenditure. Attempts to reduce their use have had mixed results. OBJECTIVE: To investigate the effect of an intervention based on a simple form-based system for ordering laboratory tests by physicians, on both use of laboratory resources and diagnostic accuracy. DESIGN: At Kaplan Medical Center in Rehovot , Israel , there are 4 similar Internal Medicine departments. In one department (C), the new system was initiated, whereas in the other 3 departments (A, B and D), the traditional method of ordering blood tests was continued. The intervention used was a requirement for tests to be specifically requested by residents following unbundling of test panels, with hands-on supervision by a senior physician. In addition, the residents attended a series of lectures on the economic implications of laboratory testing. The intervention study lasted for 3 years. MEASUREMENTS: Total number of tests performed in each department, number of tests per admission and total cost of each test at Medicare reimbursement prices. RESULTS: The number of tests per admission prior to the intervention was 1.91 +/- 0.89; it decreased for each of the next 3 years: 0.76 +/- 0.61, 0.80 +/- 0.62 and 0.78 +/- 0.63 respectively. There was a total decrease of 97,365 tests during the 3-year period, saving 1,914,149 dollars. There was no difference in the readmission rate or in the number of diagnoses of conditions based primarily on blood tests such as hypokalemia or hyponatremia, between department C and the other departments. CONCLUSIONS: The intervention developed here produced significant and sustained reduction of financial savings in the number of laboratory tests ordered, without negatively impacting diagnostic capability or patient care.

Splenic embolus: 13 cases from a single medical department.

BACKGROUND: Despite the spleen having a very rich blood supply, there is a paucity of reports of splenic emboli. OBJECTIVES: To investigate the incidence of splenic emboli treated in a single general internal medicine department over the last 3 years. METHODS: We examined the records of a 35 bed internal medicine department in a hospital in the center of Israel. RESULTS: Over a period of 3 years 13 patients admitted to one internal medicine department developed acute abdominal pain and areas of hypoperfusion in the spleen on contrast computed tomography imaging. The patients were treated with anticoagulants, their course was benign and there were no long-term sequelae. CONCLUSIONS: Embolus to the spleen is not rare in an internal medicine department. Diagnosis can be easily made by contrast CT scanning, and treatment with anticoagulants results in a good prognosis.

Real-time PCR for Strongyloides stercoralis-associated meningitis.

Four immunocompromised patients, immigrants from Ethiopia, presented with diverse clinical manifestations of meningitis associated with Strongyloides stercoralis dissemination as determined by identification of intestinal larvae. The cerebrospinal fluid of 3 patients was tested by a validated (for stool) real-time PCR for S. stercoralis and was found positive, establishing this association.

Acute renal embolism. Forty-four cases of renal infarction in patients with atrial fibrillation.

Acute renal embolus is rarely reported in the medical literature; thus, accurate data regarding presentation, laboratory tests, diagnostic techniques, and treatment are lacking. To better define this condition, we examined the medical records of all patients admitted to Kaplan Medical Center and Sheba Medical Center in central Israel from 1984 to 2002 who had a diagnosis of renal infarction and atrial fibrillation. We noted demographic, clinical, and laboratory parameters; method of diagnosis; treatment received; and patient outcome. We identified 44 cases of renal embolus: 23 females and 21 males, with an average age of 69.5 +/- 12.6 years. Thirty (68%) patients had abdominal pain, and 6 (14%) had a previous embolic event. Nine patients were being treated with warfarin on admission, 6 (66%) of whom had an international normalized ratio (INR) < 1.8. Hematuria was present in 21/39 (54%), and 41 (93%) patients had a serum lactate dehydrogenase (LDH) level > 400 U/dL. The mean LDH was 1100 +/- 985 U/dL. Diagnostic techniques included renal isotope scan, which was abnormal in 36/37 cases (97%); contrast-enhanced computed tomography (CT) scan, which was diagnostic in 12/15 cases (80%); and ultrasound, which was positive in only 3/27 cases (11%). Angiography was positive in 10/10 cases (100%). Twenty-three (61%) of 38 patients had normal renal function on follow-up. The 30-day mortality was 11.4%. Renal embolus was diagnosed mainly in patients aged more than 60 years, some of whom had a previous embolic event. Most of those receiving anticoagulant therapy had a subtherapeutic INR. Abdominal pain was common, as well as hematuria and an elevated LDH. These patients are at risk of subsequent embolic events to other organs. The most sensitive diagnostic technique in this population is a renal isotope scan, but contrast-enhanced CT scan requires further assessment.

Helicobacter pylori: friend or foe?

Helicobacter pylori (H. pylori) is a Gram-negative spiral bacterium that is present in nearly half the world's population. It is the major cause of peptic ulcer disease and a recognized cause of gastric carcinoma. In addition, it is linked to non-ulcer dyspepsia, vitamin B12 deficiency, iron-deficient anemia and immune thrombocytopenic purpura. These conditions are indications for testing and treatment according to current guidelines. An additional indication according to the guidelines is "anyone with a fear of gastric cancer" which results in nearly every infected person being eligible for eradication treatment. There may be beneficial effects of H. pylori in humans, including protection from gastroesophageal reflux disease and esophageal adenocarcinoma. In addition, universal treatment will be extremely expensive (more than $32 billion in the United States), may expose the patients to adverse effects such as anaphylaxis and Clostridium difficile infection, as well as contributing to antibiotic resistance. There may also be an as yet uncertain effect on the fecal microbiome. There is a need for robust clinical data to assist in decision-making regarding treatment of H. pylori infection.

Fatal ventricular arrhythmia as a complication of transesophageal echocardiography.

AIM: To report a case of serious ventricular arrhythmia during transesophageal echocardiography. METHODS AND RESULTS: A 58-year-old woman with previous mitral and tricuspid valve replacement and permanent pacemaker implantation suffered from recurrent fever and Staphylococcus aureus bacteremia. Transesophageal echocardiography was performed as part of the assessment for infective endocarditis. During this procedure the patient developed sustained ventricular tachycardia and subsequently ventricular flutter. She was successfully resuscitated. Subsequently the procedure was undertaken under general anesthesia with no complications. CONCLUSION: The increasing use of TEE in a wider spectrum of patients, many of whom are seriously ill, may result in serious side-effects.

Acute cholestatic hepatitis after exposure to isoflurane.

OBJECTIVE: To report a case of acute cholestatic hepatitis following exposure to the inhalational anesthetic isoflurane. CASE SUMMARY: A 70-year-old healthy woman from Iraq developed acute cholestatic hepatitis 3 weeks following repair of the right rotator cuff under general anesthesia. There was no evidence for viral, autoimmune, or metabolic causes of hepatitis. No other medications were involved except for dipyrone for analgesia. The alanine aminotransferase was elevated to a peak concentration of 1533 U/L and the serum bilirubin reached a peak of 17.0 mg/dL. There was slow improvement over 4 months. Accidental reexposure by the patient to dipyrone was uneventful. DISCUSSION: The clinical and histologic picture of this case resembles halothane hepatitis, which has a significant mortality rate. CONCLUSIONS: Isoflurane, a common anesthetic agent, can cause severe cholestatic hepatitis.