Changes of FASH ultrasound findings in TB-HIV patients during anti-tuberculosis treatment.

Ultrasound findings of extra-pulmonary tuberculosis (TB) have been well-described, particularly in human immunodeficiency virus (HIV) co-infected patients, and are often used as a basis of diagnosis in high-prevalence settings. Changes in findings during anti-tuberculosis treatment are less well documented. We present a single-centre case series of 21 TB-HIV co-infected individuals with typical ultrasound findings present at baseline. In 16/21 (76%) patients, all findings had resolved by month 3 of treatment. In patients with persistent ultrasound findings at 3 months, non-adherence, drug resistance, chronic disease, immune-reconstitution inflammatory syndrome and alternative diagnoses were identified. Follow-up ultrasound at month 3 may help identify high-risk cases.

Diagnostic value of FASH ultrasound and chest X-ray in HIV-co-infected patients with abdominal tuberculosis.

In human immunodeficiency virus (HIV) co-infected tuberculosis (TB) patients with negative acid-fast bacilli smears, chest radiography (CXR) is usually the first imaging step in the diagnostic work-up. Ultrasound, also in the form of focused assessment with sonography for TB-HIV (FASH), is an additional imaging modality used to diagnose extra-pulmonary TB (EPTB). Findings from 82 patients with abdominal TB diagnosed by ultrasound were analysed and compared with CXR results. Enlarged abdominal lymph nodes were seen in 75.6% of the patients, spleen abscesses in 41.2% and liver lesions in 30.6%. CXR showed a miliary pattern in 21.9% of the patients; 26.8% of the CXR had no radiological changes suggestive of pulmonary TB. This patient group would benefit from ultrasound in diagnostic algorithms for HIV-associated EPTB.

Ultrasound and infections on the Tibetan Plateau().

INTRODUCTION: The authors report on an ultrasound (US) outreach program for the nomadic people living in Yushu, a remote area of Qinghai, Tibet, People's Republic of China (PRC) about 4800 m above sea level. The program was carried out in cooperation with ROKPA INTERNATIONAL, a non-profit organization (NGO) that aims at helping the poorest peoples living in remote regions of the world. MATERIALS AND METHODS: A hand-held US scanner (Sonosite 180 Plus, Sonosite Inc., Bothell, WA, USA) equipped with a 3.5-5 MHz convex probe was used at a local clinic for 21 days in 2007 and for 32 days in 2009. RESULTS: A total of 1128 US examinations were performed (578 in 2007 and 550 in 2009). The main diagnoses were: Echinococcal cysts (66 cases; 6.23%) - Biliary tract and intrahepatic gallstones (10% of patients examined) - Ascariasis - Acute and chronic hepatitis, liver cirrhosis, abdominal masses - Abdominal tuberculosis - Miscellaneous (trophoblastic tumor, megacalicosis, splenomegaly in acute leukemia). After the first experience in 2007, collaboration with the local hospital was established for the treatment of patients affected by active echinococcal cysts using albendazole and puncture, aspiration and injection of scolicidal agent and re-aspiration (PAIR) and subsequent follow-up. DISCUSSION AND CONCLUSIONS: US scanning was well accepted by the local population and allowed diagnosis, classification and choice of treatment of the echinococcal cysts according to recent criteria based on a stage-specific approach. Percutaneous treatment was also introduced, but more training of local healthcare providers is needed to secure continuation of this practice. Further experience may help improve the standard of health care services offered to the nomadic populations in this remote area.

Acute hepatitis C: clinical aspects, diagnosis, and outcome of acute HCV infection.

Acute hepatitis C virus (HCV) infection is often a clinically silent infection, and is therefore rarely detected. A high index of clinical suspicion in addition to careful serological and virological assessment is required to identify the disease, and to determine the eventual clinical outcome after primary infection; the minority of acutely infected individuals spontaneously control viremia in long term whilst the majority become persistently infected. Here, we describe the clinical presentation of acute HCV infection and the patterns of viremia and liver alanine transaminase levels (ALT) observed. We discuss the serological and virological assessment and potential pitfalls in accurately diagnosing acute HCV. Good prospective studies that identify host and virological factors that determine clinical symptoms and disease outcome are difficult to perform due to the asymptomatic nature of infection, but some progress has been made in this field. Host factors including gender, age at time of infection, prior resolution of infection, symptomatic infection and host immune responses, and viral factors such as the nature of the infecting quasispecies and more speculatively viral genotype, are some features that have been correlated with disease outcome. In spite of this, on an individual patient level, it is currently not possible to predict those that will resolve infection. Identifying, in detail therefore, those factors that are responsible for viral control remains an important research goal not only to aid clinical management but also to develop effective treatment and vaccination strategies.

[Off-label antibiotic use: malpractice or good clinical practice?]. / La prescrizione off-label di antibiotici: malpractice o buona pratica clinica?

In Italy, off-label drug use has been forbidden since 1998. However, Italian law allows off-label treatment for single cases only if treatment is considered irreplaceable, and completely under physician responsibility. To assess the consequences of such regulations for the infectious diseases specialist, we listed the indications of intravenous and oral antibiotics available in our hospital pharmacy service, and discussed them in a pool of nine infectious diseases specialists. Indications were compared with the recommended treatment of major bacterial syndromes as suggested by the major guidelines and textbooks. We found that standard treatment for several bacterial infections is off-label. The pool of specialists concluded that some off-label use of antibiotics is vital to daily practice in infectious diseases. Scientific societies should promote guidelines as the standard reference for good clinical practice, which should not be based only on the respect of drug labels.

Assessing patients' understanding of hepatitis C virus infection and its impact on their lifestyle.

AIMS: To assess how much patients with hepatitis C virus infection know about their condition and what impact it has on their lifestyle. MATERIALS AND METHODS: A multiple-choice questionnaire was administered anonymously to 364 hepatitis C virus-infected subjects just before their first specialist visit. RESULTS: Even before hepatitis C virus infection was diagnosed, 257 subjects (70.6%) already knew something about this infection. Overall, 36% of patients had changed the way they behaved within the family, 25.5% had changed their sexual habits, 46.9% had changed their diet, and 69% reported having stopped or limited their alcohol intake after being told they were hepatitis C virus positive. Hepatitis C virus infection had a negative impact on the psychological status in 44.2% of patients. This effect was significantly greater among women and was independent of either the duration of their infection or any counselling received from the general practitioner. The need for specific treatment was reported by 59.8%. A demand for more detailed information about hepatitis C virus was expressed by 89.9% of patients. CONCLUSIONS: Hepatitis C virus changes all aspects of lifestyle and psychological status. The patients' strong demand for more information suggests that counselling and educational programmes must be an integral part of the activities of both the general practitioner and the specialist.

Impact of liver steatosis on virological response in [corrected] Italian patients with chronic hepatitis C treated with peg-interferon alpha-2b plus ribavarin.

BACKGROUND: Whether liver steatosis affects sustained virological response in patients with chronic hepatitis C is still under discussion. AIM: To evaluate the impact of liver steatosis in patients treated (for chronic hepatitis C) with combination therapy. METHODS: We evaluated 97 (male/female 82/15, mean age 41.1 years) consecutive naive patients treated with pegylated interferon alpha-2b plus ribavirin. RESULTS: Prevalence and severity of liver steatosis were significantly associated with genotype 3a [grade 3-4 in 14 of 32 patients (44%) vs. 8 of 65 patients (12%) with other genotypes; P = 0.001], while steatosis grade 1 (<10% of hepatocytes affected) was more frequently associated with genotype 1a/1b [9/39 (23%) vs. 4/57 (7%); P = 0.02]. Overall, sustained virological response was 62.8%, and was statistically uninfluenced by the presence/absence of liver steatosis. On the contrary, the following variables were independently associated with sustained virological response at logistic regression analysis: genotype other than 1a/1b, positive association, (odds ratio 3.4, P < 0.04), and low-grade liver steatosis, negative association, (odds ratio 9.0, P = 0.009), whereas sustained virological response was unaffected by severe liver steatosis, which was mainly associated with genotypes 2 and 3 [steatosis grade 2, 18/29 (62%); grade 3, 10/12 (83%); grade 4, 7/10 (70%)]. CONCLUSIONS: Only low-grade liver steatosis negatively affects the outcome of combination therapy, with peginterferon alpha-2b plus ribavirin, while severe steatosis (which is virus-related in most cases) has no impact on virological response.

Therapy of chronic hepatitis C virus infection in HIV co-infected people.

The introduction of highly active anti-retroviral therapy (HAART) for Human Immunodeficiency Virus (HIV) infection has significantly improved the life expectancy of HIV positive patients. Hepatitis C virus (HCV) co-infection is common in HIV infected patients and is now a significant cause of morbidity and mortality. Optimal management and treatment of HCV in HIV infected patients is therefore essential. Interferon-alpha (IFN-alpha) and ribavirin is the mainstay of treatment for HCV infection in HIV infected people. The sustained virological response rate (SVR) with combination therapy is lower than that commonly observed in HCV mono-infected patients. This is, at least in part, due to the very high treatment drop out rates. Ribavirin in combination with HAART is associated with particular side effects such as mitochondrial toxicity. Therefore, vigilant monitoring of patients during therapy, in specialist centers is essential. Pegylated interferon (PEG-IFN) plus ribavirin is particularly promising as it is easier to administer and will probably become the treatment of choice for co-infected patients. A SVR is associated with genotype 2 and 3, in addition to a high CD4+ cell count and a low HCV load prior to therapy. The progression of HCV related liver disease in HIV positive patients is faster than in subjects with HCV infection alone. As a result, there is an increasing incidence of cirrhosis and end-stage liver disease in co-infected patients. Liver transplantation is being evaluated in many centers. To date the experiences are very limited but encouraging in term of survival rate.