[Free dermal fat graft for coverage of the median nerve following failed carpal tunnel release]. / Le greffon dermohypodermique pour la couverture du nerf médian au poignet: résultats cliniques et paracliniques.

OBJECTIVES: We wished to evaluate the effectiveness of a free dermal fat graft for covering the median nerve in order to improve function after failure of carpal tunnel release. METHODS: Eight patients with nine failures of carpal tunnel release were reviewed for this retrospective study. They all had significant perineural fibrosis. We performed a free dermal fat graft harvested from the inguinal region on the same side. The mean follow-up was 37 months (range 6 to 112). All patients had a clinical examination, a disability arm and shoulder scoring (DASH) and magnetic resonance imaging (MRI). RESULTS: Five patients were satisfied or very satisfied with the procedure although only two patients returned to work. Mean grip strength was 13 kg (43% of non-operated hand) and the two-point discrimination test was normal or subnormal six times on the eight wrists tested. The mean DASH score was 43 out of 100. MRI scans on eight wrists showed a fat signal in all patients and enhanced signal with gadolinium contrast in six cases. CONCLUSIONS: Free dermal fat graft offers a good covering for the median nerve over the carpal tunnel in cases of failure of carpal tunnel release. MRI showed viability of the graft. Clinical results show improvement but symptoms of median nerve irritation persisted. Permanent intraneural changes may explain these limited results.

Utility of QuantiFERON-TB Gold in-tube testing for latent TB infection in HIV-infected individuals.

SETTING: Urban inner city human immunodeficiency virus (HIV) clinic. OBJECTIVE: To evaluate tuberculin skin testing (TST) and QuantiFERON-TB Gold (QFT-G) testing in an HIV-infected population relative to the presence of risk factors for latent tuberculosis infection (LTBI). DESIGN: Cross-sectional analysis of the response of a whole blood gamma interferon release assay to early secreted antigenic target 6 (ESAT-6) and culture filtrate protein 10 (CFP-10) antigens and TST relative to known risk factors for LTBI. RESULTS: Of 207 subjects enrolled, four were excluded due to missing data and three specimens yielded discordant results. Ten specimens were indeterminate due to inadequate response to mitogen. All indeterminate results occurred in subjects with CD(4) counts <200 cells/mm(3). Eleven QFT-G results and 13 TST results were positive. The concordance between TST and QFT-G was poor (kappa 0.38). QFT-G results were more likely than TST to be associated with risk factors for LTBI. CONCLUSIONS: QFT-G, but not TST, showed a statistically significant association between the number of risk factors for LTBI and a positive result (OR 1.6). QFT-G testing may be more useful than TST in individuals with HIV infection.

[Endoscopic treatment of snapping scapula]. / Traitement endoscopique des accrochages scapulothoraciques.

We describe an endoscopic method for resection of the superomedial comer of the scapula in cases of painful snapping scapula. A preoperative computed tomography may be useful to show narrowing between the superomedial comer and the chest wall. Endoscopic technique gives the same goods results than open surgery with in cosmetic advantage and early rehabilitation. Avoided neurological lesion need to perform a precise portal placement.

[Endoscopic treatment of snapping scapula.] / Traitement endoscopique des accrochages scapulothoraciques.

We describe an endoscopic method for resection of the superomedial corner of the scapula in cases of painful snapping scapula. A preoperative computed tomography may be useful to show narrowing between the superomedial corner and the chest wall. Endoscopic technique gives the same goods results than open surgery with in cosmetic advantage and early rehabilitation. Avoided neurological lesion need to perform a precise portal placement.

Circular viral DNA and anomalous junction sequence in PBMC of HIV-infected individuals with no detectable plasma HIV RNA.

Closed circular (cc) forms of extrachromosomal HIV DNA are detected in patients with high viral loads; however, it is unclear whether these forms remain if virus replication is suppressed to undetectable levels by combination antiretroviral therapy. A nested primer polymerase chain reaction amplification assay was used to detect the presence of ccDNA containing two long terminal repeat sequences (2-LTR) in PBMC of patients with low or undetectable plasma HIV RNA. Fifty percent of patients with plasma RNA levels <50 copies/ml of blood had detectable 2-LTR DNA. Sequencing of the products identified normal LTR--LTR junctions in the minority of cases with the majority containing anomalies including deletions and insertions. The persistence of HIV ccDNA in patients with no detectable plasma RNA could be consistent with ongoing de novo infection of dividing cells or with stability of this form of DNA in nondividing cells.

Infectious disease. Update on treatment of pneumonia, influenza, and urinary tract infections.

Older persons are at increased risk for infection because of decreased physiologic reserves, acute and chronic comorbidities, time spent in hospitals or nursing homes, and high exposure to invasive procedures in those settings. Management of infection in older persons is complicated by several factors, including microbial resistance and the infrequency or absence of common infection signs and symptoms. Among the most common infections in older populations are community-acquired pneumonia, influenza, and urinary tract infection. Vigilance, early diagnosis, and strategic use of antibacterial or antiviral agents are key to effective patient management.

Highly active antiretroviral therapy decreases mortality and morbidity in patients with advanced HIV disease.

BACKGROUND: Mortality and morbidity related to AIDS have decreased among HIV-infected patients taking highly active anti-retroviral therapy (HAART), but previous studies may have been confounded by other changes in treatment. OBJECTIVE: To assess the benefit of HAART in patients with advanced AIDS and anemia. DESIGN: Prospective, multicenter cohort study. SETTING: The Viral Activation Transfusion Study (VATS), with enrollment from August 1995 through July 1998 and follow-up through June 1999. PATIENTS: 528 HIV-infected patients with cytomegalovirus (CMV) seropositivity or disease who were receiving a first red blood cell transfusion for anemia. MEASUREMENTS: In a person-year analysis of follow-up before and after initiation of HAART, Poisson regression was used to calculate crude rate ratios and rate ratios adjusted for CD4 count, HIV RNA level, calendar period, time on study, sex, ethnicity, and injection drug use. RESULTS: At baseline, patients had a median CD4(+) lymphocyte count of 0.015 x 10(9) cell/L, median plasma HIV RNA level of 4.8 log(10) copies/mL, and median hemoglobin concentration of 73 g/L. Use of HAART increased from 1% of active patients in January 1996 to 79% of active patients in January 1999. The crude death rate was 0.24 event/person-year among patients taking HAART and 0.88 event/person-year among those not taking HAART (rate ratio, 0.26; adjusted rate ratio, 0.38; P < 0.001 for both comparisons). Rates of non-CMV disease were 0.15 event/ person-year after HAART and 0.45 event/person-year before HAART (crude rate ratio, 0.34 [ P < 0.001]; adjusted rate ratio, 0.66 [ P < 0.05]). Rates of CMV disease were 0.10 event/person-year after HAART and 0.25 before HAART (crude rate ratio, 0.42 [ P < 0.01]; adjusted rate ratio, 1.01 [ P > 0.2]). Results were similar in patients with baseline CD4(+) lymphocyte counts less than 0.010 x 10(9) cells/L. CONCLUSIONS: The data support an independent reduction in mortality and opportunistic events attributable to HAART, even in patients with very advanced HIV disease. However, patients with CMV infection or disease may not have a reduction in new CMV events due to HAART.

Qualitative and quantitative PCR measures of cytomegalovirus in patients with advanced HIV infection who require transfusions.

The Viral Activation Transfusion Study (VATS) was a randomized trial that compared leukocyte-reduced transfusions with unfiltered red blood cell transfusions in HIV and cytomegalovirus (CMV) antibody-positive patients with anemia who were undergoing their first blood transfusion. The relations of the baseline qualitative and quantitative polymerase chain reaction (PCR) measures of plasma CMV viremia, HIV RNA, CD4(+) cell counts, and quality of life in these study subjects were examined. The 511 study subjects had a median CD4(+) cell count equal to 15 cells/mm3, and 110 (21.5%) had CMV viremia by qualitative assay. In multivariate models, frequency of positive qualitative CMV increased with decreasing CD4(+) cell counts (p =.04 trend), higher HIV RNA (p <.001), and a history of CMV disease (p <.001). Quantitative CMV PCR were performed on the 110 qualitative assay-positive study subjects. Median CMV viral load was 1780 copies/ml. In multivariate regression models, lower CD4(+) cell count (p =.03), and a history of CMV disease (p <.001) correlated with the level of CMV load. HIV RNA load and CMV load were not correlated. A lower Karnofsky score was associated with both the presence and quantity of CMV DNA.

An unusual manifestation of acquired syphilis.

Bone involvement is an unusual manifestation of acquired syphilis. We report a case of clinically apparent osteitis of the skull, secondary to acquired syphilis, which was the patient's presentation of human immunodeficiency virus infection.

Determinants of antimicrobial prophylaxis use and treatment for wasting among patients with advanced human immunodeficiency virus disease in the United States, 1995-1998.

Despite US Public Health Service (USPHS) recommendations for antimicrobial prophylaxis for patients with advanced human immunodeficiency virus (HIV) disease, the proportion of patients who receive prophylaxis is not known. We measured the prevalence of antimicrobial prophylaxis use, and treatment for HIV wasting at baseline among 531 patients with advanced HIV disease enrolled in a multicenter randomized trial of red blood cell transfusion. Use of antimicrobial prophylaxis and treatment for wasting in the 30 days before enrollment was ascertained in patients eligible for primary prophylaxis, secondary prophylaxis, or both, according to USPHS guidelines. There was high utilization of primary and secondary Pneumocystis carinii pneumonia prophylaxis, variability in primary Mycobacterium avium complex prophylaxis by center, and low use of primary cytomegalovirus prophylaxis. Treatment of wasting was more common in white than nonwhite patients and in patients with HIV disease who lived in the region west of the Mississippi River of the United States versus those whose lived in the eastern region.

Thallium-201 retention in focal intracranial lesions for differential diagnosis of primary lymphoma and nonmalignant lesions in AIDS patients.

UNLABELLED: The purpose of this study was to determine whether 201Tl retention in focal intracranial lesions can help distinguish central nervous system (CNS) lymphoma from toxoplasmosis and other nonmalignant CNS lesions in patients with acquired immunodeficiency syndrome. METHODS: Forty-nine patients who presented with focal lesions on CT and/or MRI had 201Tl brain SPECT studies (early and delayed image sets) performed shortly after admission. Early and delayed 201Tl uptake ratios were obtained for the positive studies, and the retention index of thallium was calculated (delayed/early target-to-background mean count ratio). RESULTS: Twenty-nine patients had foci of significantly increased 201Tl uptake on the early images in regions of corresponding CT/MRI lesions. Ten of these patients had biopsy-proven lymphomas. Another patient was found to have metastatic adenocarcinoma. Twelve additional patients had a response to radiation therapy or a clinical course consistent with lymphoma and six patients had a false-positive SPECT study. The early uptake ratio could not separate malignant from nonmalignant lesions. The 201Tl retention index in patients with lymphomas (1.18 +/- 0.16) was significantly higher than the retention index in adenocarcinoma (0.24) and in the six nonmalignant lesions (0.62 +/- 0.07). The lowest retention index in patients with lymphoma was 1.07, and the highest retention index in nonmalignant lesions was 0.70. Twenty patients showed no 201Tl uptake in the regions of CT/MRI lesions. Three of them had biopsies consistent with a benign etiology, and one patient was diagnosed with tuberculosis. Fifteen patients improved clinically on antitoxoplasmosis medications alone, and one patient had CNS lymphoma. The overall sensitivity of 201Tl brain SPECT was 96%. The specificity was 76% by counting all studies with abnormal 201Tl uptake, but it increased to 100% when the retention index was also considered. CONCLUSION: The retention index increases the specificity of 201Tl brain SPECT in human immunodeficiency virus patients. In the presence of abnormal early 201Tl uptake, it is essential to perform delayed imaging and calculate the retention index to distinguish nonmalignant lesions from lymphoma. The absence of 201Tl uptake on early images at the site of a CT/MRI abnormality excludes the diagnosis of lymphoma with a high degree of confidence and delayed imaging is unnecessary.

Cardiac tamponade in a patient with AIDS: a review of pericardial disease in patients with HIV infection.

Pericarditis in patients with human immunodeficiency virus (HIV) infection may be asymptomatic or symptomatic, but is sometimes overlooked because of signs and symptoms of other organ system diseases. A case report of cardiac tamponade in a patient with acquired immunodeficiency syndrome (AIDS) is presented. To determine the incidence and causes of pericardial disease in patients with HIV infection, a review of the literature was conducted. Fifteen autopsy and echocardiographic series involving 1139 patients with HIV infection reveal that the average incidence of pericardial disease is 21%. Most cases are asymptomatic and without an identifiable cause. However, in those that are symptomatic, about two thirds are caused by infection or neoplasm; one third have an undetermined etiology. In the 66 published cases of cardiac tamponade in patients with HIV infection, 26% are caused by tuberculosis, 17% are purulent, and 8% are caused by Mycobacterium avium-intracellulare (MAI). Lymphoma and Kaposi's sarcoma are each responsible for 5% of the effusions. Less frequent causes of tamponade are Cryptococcus neoformans, cytomegalovirus, and Mycobacterium kansasii. Small asymptomatic pericardial effusions in patients with HIV infection do not require diagnostic evaluation. However, large symptomatic pericardial effusions should be investigated, because two thirds are caused by potentially treatable infections or neoplasms.

Rapid differential diagnosis of cerebral toxoplasmosis and primary central nervous system lymphoma by thallium-201 SPECT.

UNLABELLED: This study sought to assess whether 201Tl brain SPECT can significantly reduce the time required for the differential diagnosis of primary central nervous system (CNS) lymphoma and cerebral toxoplasmosis in patients with AIDS. METHODS: Eighteen patients who presented with focal lesions on CT or MRI, or both, underwent 201Tl brain SPECT shortly after admission and before a CT-guided stereotactic brain biopsy. Early and delayed 201Tl uptake ratios were obtained for patients with positive 201Tl study results, and the retention index of 201Tl was calculated. RESULTS: Ten patients had 11 foci of significantly increased 201Tl uptake in regions of corresponding CT/MRI lesions. Five of these patients had biopsy-proven lymphomas, one of them in two separate foci. Another patient was found to have metastatic adenocarcinoma. Three patients had a clinical course and response to radiation therapy consistent with lymphoma, and study results in another patient were considered falsely positive. Of nine patients with no 201Tl uptake in regions of CT/MRI lesions, two had biopsy findings consistent with a benign etiology, and the other seven improved clinically on antitoxoplasmosis medications alone. The overall sensitivity of 201Tl brain SPECT was 100%, and specificity was 90%. The 201Tl retention index in patients with lymphomas was significantly higher than that in patients with adenocarcinomas and nonmalignant lesions (1.35 +/- 0.16 versus 0.24 and 0.56, respectively). CONCLUSION: Thallium-201 brain SPECT is a sensitive and specific method for rapid differential diagnosis of CNS lymphoma and toxoplasmosis in patients with AIDS. The 201Tl retention index is useful in differentiating CNS lymphomas from other malignant and nonmalignant pathologies.

Circulating Borrelia burgdorferi in patients with acute Lyme disease: results of blood cultures and serum DNA analysis.

To determine the usefulness of blood culture and polymerase chain reaction (PCR) analysis in detecting circulating Borrelia burgdorferi or its DNA, blood and serum from untreated patients with acute Lyme disease were examined. None of the cultures of blood or serum from the 7 patients tested demonstrated spirochetes. Similarly, all patient serum samples, assayed in two laboratories, were negative for B. burgdorferi DNA using PCR amplification. These results suggest that in patients with acute Lyme disease, spirochetes, spirochete DNA, or both circulate early, only intermittently, or at low levels and that neither culture nor PCR testing of blood or serum, as currently done, appears likely to prove generally useful in the diagnosis of Lyme disease.

Differential inhibition of human T-lymphocyte activation by maleimide probes.

Cellular thiols are known to be involved in lymphocyte activation, differentiation, and growth. In theory, alkylation of selective cellular thiols could be used to regulate specific processes in the activation sequence by inactivating particular enzymes or structural proteins, although to date specific alkylating probes have not been reported. N-Ethylmaleimide (NEM) is a lipophilic sulfhydryl-alkylating agent that is known to block the in vitro proliferative response of T lymphocytes. NEM (10 microM) was found to be fully inhibitory in PHA, Con A, and MLC assays only when added prior to or simultaneously with the mitogens or allogeneic cells; the addition of NEM only 15 sec after stimulating the cells with PHA resulted in a loss of greater than 50% of the inhibitory activity. The addition of 50 microM 2-ME 10 min after treating the cells with NEM failed to block the inhibitory effect. NEM (10-20 microM) had no adverse effect on lymphocyte viability, but completely blocked lymphocyte agglutination in response to mitogens or allogeneic cells. The lymphocytes overcame the inhibitory effects of NEM after 48 hr in both the PHA and MLC experiments. Resumption of the proliferative response was associated with the onset of agglutination in the PHA assay. In experiments using various analogs of NEM, we noted that the presence of a nonpolar N-linked side group was necessary for inhibitory activity. Pretreatment of PBMC with NEM decreased the total cellular thiols by 50% and blocked proliferation by 99%, whereas N-hydroxymaleimide decreased the total cellular thiols by 38% but had no effect on the proliferative response. The additional 12% of the cellular thiols that react with NEM, but not NHM, account for the inhibitory effect of NEM on lymphocyte proliferation. These findings suggest that selective cellular thiols are critical for T-cell activation.

Phenotypic modification of SV40-transformed hamster lymphoid cells in vivo.

Explants of simian virus 40 (SV40)-induced lymphoid tumors yield SV40-T-antigen-positive derivatives that differ from GD248 lymphocytes propagated in suspension culture, (or in vivo), in the following respects: polygonal shape, adhesion to culture substrates in vitro, phagocytic capacity, lack of immunoglobulin and a chromosome complement at least twice that of GD248 lymphocytes. When GD-248 lymphocytes are propagated as suspension in vitro, no such adherent variants can be detected. However, sequential in vivo passage of GD248 lymphocytes obtained from the suspension-culture lines also yield adherent cell lines upon explanation in vitro. Injection of adherent cells into hamsters produces tumors with histological features of reticulum cell sarcoma.