Structured antiretroviral treatment interruptions in chronically HIV-1-infected subjects.

The risks and benefits of structured treatment interruption (STI) in HIV-1-infected subjects are not fully understood. A pilot study was performed to compare STI with continuous highly active antiretroviral therapy (HAART) in chronic HIV-1-infected subjects with HIV-1 plasma RNA levels (VL) <400 copies per ml and CD4(+) T cells >400 per microl. CD4(+) T cells, VL, HIV-1-specific neutralizing antibodies, and IFN-gamma-producing HIV-1-specific CD8(+) and CD4(+) T cells were measured in all subjects. STIs of 1-month duration separated by 1 month of HAART, before a final 3-month STI, resulted in augmented CD8(+) T cell responses in all eight STI subjects (P = 0.003), maintained while on HAART up to 22 weeks after STI, and augmented neutralization titers to autologous HIV-1 isolate in one of eight subjects. However, significant decline of CD4(+) T cell count from pre-STI level, and VL rebound to pre-HAART baseline, occurred during STI (P = 0.001 and 0.34, respectively). CD4(+) T cell counts were regained on return to HAART. Control subjects (n = 4) maintained VL <400 copies per ml and stable CD4(+) T cell counts, and showed no enhancement of antiviral CD8(+) T cell responses. Despite increases in antiviral immunity, no control of VL was observed. Future studies of STI should proceed with caution.

Atraumatic pneumocephalus: a case report and review of the literature.

Pneumocephalus or air within the cranial vault is usually associated with disruption of the skull caused by head trauma, neoplasms, or after craniofacial surgical interventions. We report a child who presented with headache and the pathognomonic "succussion splash" and was found to have atraumatic pneumocephalus from forceful valsalva maneuvers. Pneumocephalus forms, caused by either a ball-valve mechanism that allows air to enter but not exit the cranial vault, or cerebrospinal fluid (CSF) leaks, which create a negative pressure with subsequent air entry. We review the literature for traumatic and atraumatic causes of pneumocephalus, its complications, and therapy.

Management of incomplete spontaneous abortion with suction curettage in the pediatric emergency department.

Pregnancy complications, including spontaneous abortion, are increasingly common reasons for teenage girls to seek medical care in pediatric emergency departments (EDs). A protocol was implemented in our department to identify patients with spontaneous abortion who would be candidates for outpatient management. We describe three cases of spontaneous abortion managed with suction curettage in our pediatric ED in collaboration with our obstetric/gynecologic colleagues. There are no reports in the pediatric literature regarding the role of suction curettage in the pediatric ED.

PIP: Recent growth in the pregnancy rate among US adolescents 15-19 years of age has been accompanied by increases in the numbers of teenage girls who present to pediatric emergency departments with pregnancy complications and failures. Financial and utilization factors produce incentives for the management of these patients on an outpatient basis. The pediatric emergency medicine and obstetrics/gynecology departments at Boston (Massachusetts) Medical Center developed a protocol to identify potential candidates for suction curettage in the management of incomplete abortion as an outpatient procedure. This article presents three cases of teens managed under this new protocol. These patients received a paracervical block and/or conscious sedation and underwent dilatation and evacuation without complications; they were discharged 4-7 hours after the procedure. Emotional support and information about the implications of spontaneous abortion for future pregnancy are essential program components. Typically, the procedure costs US$100-150 plus physician fees and laboratory and equipment expenses.

The ability of a single serum progesterone value to identify abnormal pregnancies in patients with beta-human chorionic gonadotropin values less than 1,000 mIU/mL.

OBJECTIVE: To determine the test performance of a single serum progesterone value <5.0 ng/mL for detecting ectopic pregnancy or other abnormal pregnancies in symptomatic ED patients with beta-hCG levels <1,000 mIU/mL. METHODS: A prospective study of progesterone levels was performed in consecutive ED patients presenting to an urban teaching hospital from December 1995 to March 1997 with abdominal pain and/or vaginal bleeding, a positive qualitative beta-hCG, and a quantitative beta-hCG value <1,000 mIU/mL. Patients were excluded if they were status-post a dilatation and evacuation procedure, had insufficient serum to run the progesterone assays, or were lost to follow-up. Progesterone values were measured from the original beta-hCG sample. Final patient diagnosis was abstracted from hospital records. RESULTS: 127 patients met eligibility criteria. 39 patients were excluded, leaving a total of 88 enrolled patients. 76 patients with abnormal pregnancies were identified [9 ectopic pregnancies, 62 abnormal intrauterine pregnancies (IUPs), 5 abnormal IUPs vs ectopic pregnancies], 71 of whom had progesterone values <5.0 ng/mL [sensitivity 71/76 (94%), 95% CI 86-98%]. 12 patients with normal pregnancies were identified, all of whom had progesterone values > or =5.0 ng/mL [specificity 12/12 (100%), 95% CI 78-100%]. CONCLUSION: A single progesterone value <5.0 ng/mL has high sensitivity and specificity in detecting abnormal pregnancy in symptomatic ED patients with beta-hCG values <1,000 mIU/mL.

Pilot study to enhance start-up of a multicenter nutrition intervention trial.

Multicenter trials are important for answering questions that require large numbers of subjects. Such trials require standardized implementation of behavioral change programs across diverse populations, regions, and staff. Researchers involved with the Trial of Nonpharmacologic Interventions in the Elderly conducted a 17-week pilot study of their most complex intervention (combined weight and sodium reduction) before actual start-up of the main study. This allowed staff to rehearse implementing the program and to identify and address intervention and standardization issues. Registered dietitians in 4 US communities recruited 28 participants for the pilot study, using eligibility criteria similar to those for the main trial. Participant evaluations reflected high satisfaction with the program materials and overall approach. Minor protocol changes suggested by results of the pilot study were made easily in time for start-up of the main study. Reductions in weight and sodium intake were less than targeted but were sufficient to suggest that the intervention would be effective under optimal conditions. This partial achievement of goals in the pilot study underscored the need to allow for a learning curve, for without it standardization and outcomes of the main study would be compromised.