Microalbuminuria in HIV disease.

BACKGROUND/AIMS: Microalbuminuria is a marker for early kidney disease and cardiovascular risk. The purposes of this study were to determine the prevalence of microalbuminuria in an HIV-infected clinic population, to test the predictive value of a single urine albumin/creatinine ratio (ACR) to identify persistent microalbuminuria and to examine covariates of microalbuminuria. METHODS: We conducted a prospective cohort study of HIV-infected subjects (n = 182) without proteinuria (urine protein/creatinine ratio ≥0.5 g/g), elevated serum creatinine, diabetes, or chronic inflammatory conditions. Subjects completed three research visits within 9 months. Microalbuminuria was defined as the geometric mean ACR of 25-355 mg/g for females and 17-250 mg/g for males. RESULTS: The prevalence of microalbuminuria was 14%. The negative predictive value of a single urine ACR determination was 98%, whereas the positive predictive value was only 74%. Microalbuminuria was similar among Black (15%) and non-Black (14%) subjects (p = 0.8). Subjects with microalbuminuria were more likely to have hypertension (p = 0.02) and metabolic syndrome (p = 0.03). While duration of HIV infection and the level of HIV viremia were similar between groups, those with microalbuminuria were more likely to have a CD4 count <200 cells/µl (p = 0.0003). In a multivariate logistic regression analysis, the only significant independent predictors of microalbuminuria were low CD4 count (p = 0.018) and current ritonavir exposure (p = 0.04). CONCLUSION: The prevalence of microalbuminuria in an HIV-infected clinic population was similar to earlier reports, and was associated with hypertension and impaired immune function. A single normal ACR determination effectively excludes microalbuminuria, whereas an elevated ACR requires confirmation.

Tracking widespread climate-driven change on temperate and tropical reefs.

Warming seas, marine heatwaves, and habitat degradation are increasingly widespread phenomena affecting marine biodiversity, yet our understanding of their broader impacts is largely derived from collective insights from independent localized studies. Insufficient systematic broadscale monitoring limits our understanding of the true extent of these impacts and our capacity to track these at scales relevant to national policies and international agreements. Using an extensive time series of co-located reef fish community structure and habitat data spanning 12 years and the entire Australian continent, we found that reef fish community responses to changing temperatures and habitats are dynamic and widespread but regionally patchy. Shifts in composition and abundance of the fish community often occurred within 2 years of environmental or habitat change, although the relative importance of these two mechanisms of climate impact tended to differ between tropical and temperate zones. The clearest of these changes on temperate and subtropical reefs were temperature related, with responses measured by the reef fish thermal index indicating reshuffling according to the thermal affinities of species present. On low latitude coral reefs, the community generalization index indicated shifting dominance of habitat generalist fishes through time, concurrent with changing coral cover. Our results emphasize the importance of maintaining local ecological detail when scaling up datasets to inform national policies and global biodiversity targets. Scaled-up ecological monitoring is needed to discriminate among increasingly diverse drivers of large-scale biodiversity change and better connect presently disjointed systems of biodiversity observation, indicator research, and governance.

d-Dimer and CRP levels are elevated prior to antiretroviral treatment in patients who develop IRIS.

Biomarkers could be useful in evaluating immune reconstitution inflammatory syndrome (IRIS). A cohort of 45 HIV-1-infected, antiretroviral treatment (ART)-naive patients with baseline CD4 T cell counts

Domestically acquired seoul virus causing hemorrhagic fever with renal syndrome-Maryland, 2008.

Hantaviruses are rodent-borne viruses capable of causing human disease. The Seoul virus is a hantavirus that causes hemorrhagic fever with renal syndrome in East Asia. To our knowledge, we report the first domestically acquired case of hemorrhagic fever with renal syndrome caused by the Seoul virus, confirmed by serology testing, reverse-transcriptase polymerase chain reaction, and nucleotide sequence analysis. The patient presented with myalgias and fever, and developed acute renal failure.

Ureteral Compromise in Laparoscopic Versus Vaginal Uterosacral Ligament Suspension: A Retrospective Cohort.

OBJECTIVES: The aim of this study was to evaluate if ureteral compromise is significantly different between laparoscopic and vaginal uterosacral ligament suspension (USLS). METHODS: This is a retrospective cohort study comparing all women who underwent laparoscopic and vaginal USLSs at 2 institutions (part of a single training program with procedures performed by 11 fellowship-trained Female Pelvic Medicine and Reconstructive Surgery gynecologic surgeons) between January 2008 and June 2013. RESULTS: A total of 208 patients in the study underwent a USLS, 148 in the laparoscopic group and 60 in the vaginal group. At baseline, there were statistically significant differences between the groups in mean age (50.4 vs 55.3 years, P = 0.008), parity (2.44 vs 2.77, P = 0.040), and prior hysterectomy (3.4% vs 11.7% in the laparoscopic and vaginal groups, respectively; P = 0.042).There were no ureteral compromises in the laparoscopic group and 6 in the vaginal group (0.0% vs 10.0%, respectively; P < 0.001). In an analysis evaluating only those ureteral compromises requiring stent placement, the higher rate of ureteral compromise in the vaginal group persisted despite exclusion of those cases requiring only suture removal and replacement (0.0% vs 5.0% in the laparoscopic and vaginal groups, respectively; P = 0.023).There was a lower median blood loss in the laparoscopic group (137.5 vs 200.0 mL, respectively; P = 0.002) as well as a lower rate of readmission (0.7% vs 6.7%, respectively; P = 0.025). There were no other significant differences in postoperative complications between the 2 groups. CONCLUSIONS: We found a lower rate of ureteral compromise in the laparoscopic approach to USLS compared with the traditional vaginal approach.

Brevibacterium endocarditis: a first report.

There are few case reports of infections caused by Brevibacterium species, and there have been no previously reported cases of endocarditis caused by any of the 6 known species of Brevibacterium. We report the first case of Brevibacterium endocarditis (caused by Brevibacterium otitidis) in a patient with prosthetic heart valves. The patient responded to 6 weeks of treatment with vancomycin and 2 weeks with gentamicin, and she has been receiving long-term maintenance therapy with oral azithromycin.

Case report: Rectal adminstration of ivermectin to a patient with Strongyloides hyperinfection syndrome.

Strongyloides hyperinfection syndrome may be complicated by paralytic ileus that interferes with the absorption of oral anti-helminthics. We report on the administration of ivermectin as a rectal enema preparation to a renal transplant recipient with Strongyloides hyperinfection syndrome and progressive ileus. Attempts at treatment using nasogastric albendazole and ivermectin were unsuccessful despite clamping the nasogastric tube after drug administration. Ivermectin tablets were ground to a powder, resuspended in a commercially available suspending agent, and administered per rectum. The suspending agent was chosen for its near-physiologic osmolality to allow longer retention, in contrast to many enema preparations that have a laxative effect. The patient improved markedly within 72 hours of initiation of the therapy per rectum and recovered fully. Ivermectin administered as an enema may be beneficial in patients with severe strongyloidiasis who are unable to absorb or tolerate oral therapy.

Hematogenous enterococcal vertebral osteomyelitis: report of 2 cases and review of the literature.

Enterococci are a major cause of bacteraemia and endocarditis and are increasingly being implicated in bone and joint infections. Hematogenous enterococcal vertebral osteomyelitis, however, has been only rarely reported. Here we present the first 2 patients from the United States and review the literature on 10 additional cases that have been published since 1967. The clinical presentation of enterococcal vertebral osteomyelitis was similar to cases due to other bacteria. Enterococcus faecalis caused most cases, consistent with its presumably increased virulence. All enterococcal cases in the literature were reported from Europe, which may be due to epidemiological differences related to antibiotic utilization and infection control practices between the US and Europe. Nine of all 12 cases were reported since 1995, which may be consistent with the increase in occurrence of enterococcal infections in general, in association with increasing patient co-morbidities, invasive procedures, and indwelling vascular devices.

Takotsubo cardiomyopathy following laparoscopic port placement in a patient with ovarian cancer.

► Gynecologic oncology patients can be exposed to both chronic and acute physical and emotional stress. ► Gynecologic oncology patients appear to represent an at-risk population for the development of Takotsubo's cardiomyopathy.

Increased prevalence of albuminuria in HIV-infected adults with diabetes.

OBJECTIVE: HIV and type 2 diabetes are known risk factors for albuminuria, but no previous reports have characterized albuminuria in HIV-infected patients with diabetes. RESEARCH DESIGN AND METHODS: We performed a cross-sectional study including 73 HIV-infected adults with type 2 diabetes, 82 HIV-infected non-diabetics, and 61 diabetic control subjects without HIV. Serum creatinine >1.5 mg/dL was exclusionary. Albuminuria was defined as urinary albumin/creatinine ratio >30 mg/g. RESULTS: The prevalence of albuminuria was significantly increased among HIV-infected diabetics (34% vs. 13% of HIV non-diabetic vs. 16% diabetic control, p = 0.005). HIV status and diabetes remained significant predictors of albuminuria after adjusting for age, race, BMI, and blood pressure. Albumin/creatinine ratio correlated significantly with HIV viral load (r = 0.28, p = 0.0005) and HIV-infected subjects with albuminuria had significantly greater cumulative exposure to abacavir (p = 0.01). In an adjusted multivariate regression analysis of HIV-infected subjects, the diagnosis of diabetes (p = 0.003), higher HIV viral load (p = 0.03) and cumulative exposure to abacavir (p = 0.0009) were significant independent predictors of albuminuria. CONCLUSIONS: HIV and diabetes appear to have additive effects on albuminuria which is also independently associated with increased exposure to abacavir and HIV viral load. Future research on the persistence, progression and management of albuminuria in this unique at-risk population is needed.

A1C underestimates glycemia in HIV infection.

OBJECTIVE: The objective of this study was to determine the relationship between A1C and glycemia in HIV infection. RESEARCH DESIGN AND METHODS: We completed a prospective cross-sectional study of 100 HIV-infected adults with type 2 diabetes (77%) or fasting hyperglycemia (23%) with measured glucose, A1C, mean corpuscular volume (MCV), and fructosamine. A total of 200 HIV-uninfected type 2 diabetic subjects matched for key demographic characteristics served as control subjects. RESULTS: Relative to the control subjects, A1C underestimated glucose by 29 +/- 4 mg/dl in the HIV-infected subjects. Current nucleoside reverse transcriptase inhibitors (NRTIs), higher MCV and hemoglobin, and lower HIV RNA and haptoglobin were associated with greater A1C-glucose discordance. However, only MCV and current NTRI use, in particular abacavir, remained significant predictors in multivariate analyses. Fructosamine more closely reflected glycemia in the HIV-infected subjects. CONCLUSIONS: A1C underestimates glycemia in HIV-infected patients and is related to NRTI use. Use of abacavir and increased MCV were key correlates in multivariate analyses. Fructosamine may be more appropriate in this setting.

Primary cutaneous fungal infections in solid organ transplantation: a case series.

Cutaneous fungal infections in solid-organ transplant patients present in a variety of nonspecific ways, requiring a high index of suspicion to diagnose correctly. In the present series of four transplant recipients, subsequent primary cutaneous fungal infections presented as papules, plaques, ulcers and subcutaneous nodules. Transplantations included one cardiac, two renal and one renal-pancreatic transplant. Fungal infections were limited to the skin; there was no evidence of disseminated disease in any case. The pathogens isolated were Scedosporium apiospermum (Pseudallescheria boydii), Alternaria species, Aspergillus fumigatus, and a coelomycete in the Coniothyrium-Microsphaeropsis complex of dark molds. Individuals were successfully treated with surgical debridement, antifungal agents, and reduction of immunosuppressive therapy. All patients and allografts survived. Accurate diagnosis, aggressive surgery and appropriate antifungal therapy, combined with close outpatient follow-up, optimize the likelihood of a cure in a transplant population.

Development and evaluation of a quantitative, touch-down, real-time PCR assay for diagnosing Pneumocystis carinii pneumonia.

A rapid (time to completion, <4 h, including DNA extraction) and quantitative touch-down (QTD) real-time diagnostic Pneumocystis carinii PCR assay with an associated internal control was developed, using fluorescence resonance energy transfer (FRET) probes for detection. The touch-down procedure significantly increased the sensitivity of the assay compared to a non-touch-down procedure. Tenfold serial dilutions of a cloned target were used as standards for quantification. P. carinii DNA has been detected in respiratory specimens from patients with P. carinii pneumonia (PCP) and from patients without clinical evidence of PCP. The latter probably represents colonization or subclinical infection. It is logical to hypothesize that quantification might prove helpful in distinguishing between infected and colonized patients: the latter group would have lower copy numbers than PCP patients. A blinded retrospective study of 98 respiratory samples (49 lower respiratory tract specimens and 49 oral washes), from 51 patients with 24 episodes of PCP and 34 episodes of other respiratory disease, was conducted. PCR-positive samples from colonized patients contained a lower concentration of P. carinii DNA than samples from PCP patients: lower respiratory tract samples from PCP and non-PCP patients contained a median of 938 (range, 2.4 to 1,040,000) and 2.6 (range, 0.3 to 248) (P < 0.0004) copies per tube, respectively. Oral washes from PCP and non-PCP patients contained a median of 49 (range, 2.1 to 2,595) and 6.5 (range, 2.2 to 10) (P < 0.03) copies per tube, respectively. These data suggest that this QTD PCR assay can be used to determine if P. carinii is present in respiratory samples and to distinguish between colonization and infection.