Concordance of genotypic resistance interpretation algorithms in HIV-1 infected patients: An exploratory analysis in Greece

PURPOSE

Genotypic resistance-related mutations in HIV-1 disease are often difficult to interpret. Different algorithms have been developed to provide meaningful application into clinical context. We aimed to compare, for the first time in Greece, the results of genotypic resistance derived from three interpretation algorithms.

METHODS

The sequences of 120 HIV 1-infected patients were tested for genotypic resistance to 19 antiretroviral (ARV) drugs (n = 2280 sequences). The interpretation results of Rega, ANRS and ViroSeq algorithms were compared.

RESULTS

Complete concordance was found for 2/19 ARV drugs, namely lamivudine and emptricitabine. Concordance was high for nucleoside reverse transcriptase inhibitors (NRTIs) and low for protease inhibitors (PIs). In inter-algorithm pairs, agreement was high between Rega and ViroSeq (kappa = 0.701), especially by ARV class, namely NRTIs (k = 0.869) and NNRTIs (k = 0.562). The only exception was noted for rilpivirine, where agreement was higher between ANRS and Rega (k = 0.410) compared to other inter-algorithm pairs (k = 0.018-0.055). By contrast, for PIs all comparisons yielded concordance equivalent to chance (k = 0.000).

CONCLUSIONS

Our exploratory analysis provided evidence of significant inter-algorithm discordances, especially for PIs and NNRTIs highlighting the importance of matching the results of different algorithms to achieve optimized risk stratification. Ongoing research could assist clinical physicians in interpreting complex genotypic resistance patterns.

Transmitted drug resistance among HIV-1 drug-naïve patients in Greece

OBJECTIVES

Despite the success of antiretroviral treatment (ART), the persisting transmitted drug resistance (TDR) and HIV genetic heterogeneity affect the efficacy of treatment. This study explored the prevalence of TDR among ART-naïve HIV patients in Greece during the period 2016-2019.

METHODS

Genotypic resistance testing was available for 438 ART-naïve HIV patients. Multivariable Poisson regression models were fitted.

RESULTS

The majority of patients were male, and there was a slight predominance of Hellenic (26.5%) over non-Hellenic (21.9%) nationality. The prevalence of TDR was 7.8%. There was a predominance of mutations for non-nucleoside reverse-transcriptase inhibitors (5.7%) over nucleoside reverse-transcriptase inhibitors (0.2%). No mutations to protease inhibitors were detected. The prevalence of resistance was 22.1% based on all mutations identified through the HIVdb interpretation system. The most frequent resistance sites were E138A (9.6%), K103N (6.4%), and K101E (2.1%). The majority of detected mutations were confined to subtype A (52.6%), followed by B (19.6%). Non-Hellenic nationality was significantly associated with an increased risk of TDR (relative risk 1.32, 95% confidence interval 1.04-1.69).

CONCLUSIONS

Non-B HIV infections predominate in Greece, with an increasing trend in recent years. The prevalence of TDR remains stable. Ongoing surveillance of resistance testing is needed to secure the long-term success of ART.

Right atrial metastatic melanoma in a patient with transient ischemic attacks

A 65-year-old-man was admitted for evaluation of a transient ischemic attack. A 4.5 x 5.3-cm right atrial mass and a patent foramen ovale were identified by echocardiography. A 0.5-cm lesion was identified in the left temporal lobe of the brain by magnetic resonance imaging. Positron emission tomography was used to differentiate a tumor from an infarct in the brain. The cardiac and the brain lesions were successfully resected. Histopathologic study of the atrial and cerebral tissue demonstrated that these were metastases from a previously excised scalp desmoplastic malignant melanoma. The patient remains well at 14 months' follow-up.

Biatrial approach to cardiac myxomas: a 30-year clinical experience

Early surgical intervention for atrial myxomas mitigates morbidity and usually offers cure. The operative approach to resect these tumors is controversial. The purpose of this study was to review our experience with the biatrial approach between 1964 and 1994. The location of the myxoma was left atrium in 17 and right atrium in 3. Mean preoperative New York Heart Association functional classification was 2.7. Surgical approach to the tumor was biatrial in all patients. There were no perioperative strokes, myocardial infarctions, or deaths. Mean follow-up was 7.5 years (range, 2 mo to 27 years) with a postoperative New York Heart Association functional classification of 1.4. One late death occurred, which was unrelated to the myxoma. Advantages of biatrial approach include (1) definition of tumor pedicle by direct visualization, (2) minimal manipulation of the tumor, (3) adequate margins of excision, (4) inspection of all heart chambers, and (5) secure closure of the atrial septal defect. Long-term follow-up demonstrates the efficacy of this operative approach to atrial myxomas.

Extracorporeal circulation in the management of severe tricyclic antidepressant overdose

Extracorporeal circulation is a technique that provides precise control of circulation, oxygenation, temperature, and blood composition in patients suffering from cardiopulmonary failure. The investigators present the case of a near fatal tricyclic antidepressant overdose that failed to respond to standard therapy but was resuscitated using extracorporeal circulation.

Computed tomographic diagnosis of acute blunt pancreatic transection

Pancreatic injuries secondary to blunt trauma are challenging to diagnose. In many cases, the diagnosis is missed or delayed due to the subtle symptoms and signs of pancreatic injury. Blunt pancreatic injuries may evolve over a period of time and can be a source of extensive morbidity and mortality. Most radiologic and laboratory studies have been notoriously nonspecific in diagnosing pancreatic injuries. This article discusses three patients we treated with pancreatic transection secondary to blunt trauma, who underwent computed tomography (CT) of the abdomen on admission. The pertinent CT findings and utility of CT as a diagnostic tool in these three cases of blunt pancreatic injuries are reviewed. Abdominal CT scanning can accurately identify pancreatic injuries secondary to blunt trauma, allowing expeditious surgical intervention. A high index of suspicion for pancreatic injury combined with careful interpretation of abdominal CT scans can provide valuable information about pancreatic injury during the initial trauma assessment.

Technique for management of an axilloaxillary by-pass graft complicating a median sternotomy

A technique is presented for intraoperative management of an axilloaxillary by-pass graft when performing a median sternotomy for myocardial revascularization. This method allows continual perfusion of both upper extremities during the operation thereby preventing the potential complications of upper extremity or cerebral ischemia.

Safe use of heparin-coated bypass circuits incorporating a pump-oxygenator

Durable, covalently bonded, heparin-coated cardiopulmonary bypass (CPB) circuits with oxygenators have been developed. Proposed advantages of heparin-coated CPB circuits include improved biocompatibility and thromboresistance. The purpose of this study was to evaluate our experience with heparin-coated CPB circuits in 20 patients. Heparin was given to maintain an activated clotting time equal to or greater than 200 seconds, while flow rates were kept equal to or greater than 2 L/min. Indications for use of this circuit included recent stroke, posttraumatic injuries, recent gastrointestinal bleeding, protamine allergies, combined cardiac and noncardiac procedures, and ventricular assist. Mean heparin dosage was 0.50 +/- 0.18 mg/kg and protamine dosage was 57.14 +/- 39.36 mg. Postoperative blood loss and transfusion requirements were minimal. Postoperative complement levels of C3a and C5a were normal, suggesting excellent biocompatibility. There were no deaths or perioperative complications. Heparin-coated CPB circuits using a pump oxygenator can be used safely with low-dose heparin administration in select patients requiring CPB.

Giant, benign, mucinous cystadenoma of the ovary: case study and literature review

Benign, mucinous cystadenomas account for 15 per cent of all ovarian neoplasms. Of these, the giant variant occurs rarely. A morbidly obese, 52-year-old, white woman was seen for acute abdominal pain and diagnosed using computerized tomography as having a giant, benign, mucinous cystadenoma. At laparotomy, 21-kg cystic mass attached to the right ovary was removed. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. In such patients, special consideration must be given to hemodynamic and ventilatory monitoring and intraoperative fluid management. Recognition and subsequent surgical management of this and other large abdominal masses can be optimized by thoughtful, preoperative evaluation and careful planning of the operative approach.

The successful resuscitation of a hypothermic multitrauma patient

Accidental hypothermia due to exposure is an infrequent cause of circulatory arrest. A premature diagnosis of clinical death must be avoided in these patients and vigorous attempts at active rewarming are indicated. Extracorporeal circulation in the form of partial cardiopulmonary bypass has been reported as an effective means of rapid, even core rewarming. We wish to report a recent case at Ruby Memorial Hospital in which extracorporeal circulation was used successfully in resuscitating a profoundly hypothermic multi-trauma victim.

Left atrial to femoral arterial bypass using the biomedicus pump for operations of the thoracic aorta

Left atrial to left femoral arterial bypass is an approach to operations of the thoracic aorta dating back to the late 1950s. Since that time, various modifications of the basic bypass circuit have evolved. In addition, temporary bypass shunts have also been described in a variety of positions. The goals of bypass of the thoracic aorta regardless of the technique include prevention of distal hypoperfusion, which can lead to paraplegia, limb loss, multiple organ failure, and sometimes death. Recently, there have been reports of the use of the biomedicus centrifugal pump in bypass circuits of the thoracic aorta. Our series, as well as the success of others, using this variation of a traditional bypass circuit of the thoracic aorta, establishes the biopump's capability of minimizing inherent complications in the bypass circuit.

Revascularization of a symptomatic pseudoaneurysm of the anterior tibial artery

Traumatic pseudoaneurysms of the peripheral arterial vasculature occur infrequently. The majority of the experience with these lesions is from this century's wartime experience. Pseudoaneurysms of the tibial vessels comprise only three to seven per cent of all pseudoaneurysms and only seven cases of anterior tibial artery pseudoaneurysms have been reported in the American and British literature since World War II. A high index of suspicion must be maintained for prompt detection of these lesions. Formerly, injuries of the tibial vessels were managed by nonoperative measures or exploration and arterial ligation. These approaches were met with varying results. The evolution of current vascular surgical techniques allows successful reconstruction of these vessels. We wish to report a successful method of repair of symptomatic pseudoaneurysm of the anterior tibial artery using a saphenous vein interposition graft. This technique restored arterial continuity and allowed maximal opportunity for limb salvage. Additional management techniques are discussed and compared in order to improve rapid diagnosis and provide efficient treatment.

All terrain vehicles (ATVs). A recreational gamble

Over the period September 1985 to July 1986, the authors reviewed 28 admissions to the Level I trauma center as a result of all-terrain vehicle (ATV) accidents. The patients ranged in age from 6 to 71 years, with nearly 33 per cent (9), under age 16. There were 22 (78.6%) male and 6 (21.4%) female patients. All suffered multiple abrasions, lacerations, and contusions. In addition, 21 (75%) patients had a fracture of some type. Eight (28.6%), had head injuries and 3 (10.7%) sustained spinal cord injuries with a permanent neurologic deficit. Intrathoracic injury occurred in 2 patients (7.1%) and intraabdominal injuries occurred in 1 (3.6%). Moreover, death occurred in 3 (10.7%). Simultaneously reviewed were admissions resulting from motor vehicle accidents (MVA) and motorcycle accidents (MCA) during the same period. By comparison, the death rates (DR), fracture rates (FR), and spinal cord lesions with deficit (SLR) were significantly higher in accidents with ATVs than with MVAs or MCAs. The death rates for ATVs, MVAs, and MCAs were 10.7 per cent, 4.6 per cent, and 1.2 per cent, respectively, with significance between the MCA and ATV groups, P = .0395. The FR were 75 per cent, 53 per cent, and 65 per cent, respectively, with P = .265. SLR was found in 10.7 per cent, 2.3 per cent, and 4.4 per cent of these same groups, with P = .0001. These data suggest that ATV riders are at a higher risk for sustaining fractures, significant spinal cord injuries, or death. ATVs clearly present a health hazard to riders of all ages.

Answering the fat emulsion contamination question: three in one admixture vs conventional total parenteral nutrition in a clinical setting

Fat emulsions (FE) support microbial growth when inoculated in vitro; dextrose/amino acid solutions (D/AA) do not. Can FE be safely added to D/AA when delivered over 24 hrs? We attempted to answer this question by culturing both conventional (C) total parenteral nutrition (TPN), in which the FE and D/AA are given separately, and the 3-in-1 admixture TPN, in which all components are delivered in one bag. Two-hundred TPN fluid cultures were obtained serially by collecting 1 ml of fluid from the distal-most connection when the TPN was changed every 24 hrs. Quantiative and qualitative cultures were obtained. One hundred sixty-six (83%) were negative. Of the 34 (17%) positive cultures, 15 (17% of 88) were from the conventional system whereas 19 (17% of 112) were from the 3-in-1 system. Six clinically septic patients furnished 11 TPN fluid specimens which grew greater than 400 colonies/ml. Seven (8% of 88) of these were from the conventional system whereas four (3.6% of 112) were from the 3-in-1 system. All had distant sites of sepsis. The 23 remaining positive TPN fluid cultures grew less than 25 colonies/ml, with 20 growing Staphylococcus epidermidis. All of these patients were clinically well and there was no significant difference in the distribution of positive cultures between the conventional system (9%) and the 3-in-1 system (13%).(ABSTRACT TRUNCATED AT 250 WORDS)