Clinical outcomes and prognostic factors after HCV clearance with DAA in HIV/HCV-coinfected patients with advanced fibrosis/cirrhosis

BACKGROUND AND AIMS

We assessed long-term clinical outcomes and prognostic factors for liver disease progression after sustained viral response with direct-acting antivirals in patients coinfected with HIV/HCV with advanced fibrosis or cirrhosis.

APPROACH AND RESULTS

A total of 1300 patients who achieved sustained viral response with direct-acting antivirals from 2014 to 2017 in Spain were included: 1145 with compensated advanced chronic liver disease (384 advanced fibrosis and 761 compensated cirrhosis) and 155 with decompensated cirrhosis. The median follow-up was 40.9 months. Overall, 85 deaths occurred, 61 due to non-liver non-AIDS-related causes that were the leading cause of death across all stages of liver disease. The incidence (95% CI) of decompensation per 100 person-years (py) was 0 in patients with advanced fibrosis, 1.01 (0.68-1.51) in patients with compensated cirrhosis, and 8.35 (6.05-11.53) in patients with decompensated cirrhosis. The incidence (95% CI) of HCC per 100 py was 0.34 (0.13-0.91) in patients with advanced fibrosis, 0.73 (0.45-1.18) in patients with compensated cirrhosis, and 1.92 (1.00-3.70) per 100 py in patients with decompensated cirrhosis. Prognostic factors for decompensation in patients with compensated advanced chronic liver disease included serum albumin, liver stiffness measurement (LSM), and fibrosis 4. In this population, LSM and LSM-based posttreatment risk stratification models showed their predictive ability for decompensation and HCC.

CONCLUSIONS

Non-liver non-AIDS-related events were the leading causes of morbidity and mortality after direct-acting antiviral cure among coinfected patients with advanced fibrosis/cirrhosis. Among those with compensated advanced chronic liver disease, baseline LSM and posttreatment LSM-based models helped to assess decompensation and HCC risk.

Epidemiological trends of HIV/HCV coinfection in Spain, 2015-2019

Objectives

We assessed the prevalence of anti‐hepatitis C virus (HCV) antibodies and active HCV infection (HCV‐RNA‐positive) in people living with HIV (PLWH) in Spain in 2019 and compared the results with those of four similar studies performed during 2015–2018.

Methods

The study was performed in 41 centres. Sample size was estimated for an accuracy of 1%. Patients were selected by random sampling with proportional allocation.

Results

The reference population comprised 41 973 PLWH, and the sample size was 1325. HCV serostatus was known in 1316 PLWH (99.3%), of whom 376 (28.6%) were HCV antibody (Ab)‐positive (78.7% were prior injection drug users); 29 were HCV‐RNA‐positive (2.2%). Of the 29 HCV‐RNA‐positive PLWH, infection was chronic in 24, it was acute/recent in one, and it was of unknown duration in four. Cirrhosis was present in 71 (5.4%) PLWH overall, three (10.3%) HCV‐RNA‐positive patients and 68 (23.4%) of those who cleared HCV after anti‐HCV therapy (p = 0.04). The prevalence of anti‐HCV antibodies decreased steadily from 37.7% in 2015 to 28.6% in 2019 (p < 0.001); the prevalence of active HCV infection decreased from 22.1% in 2015 to 2.2% in 2019 (p < 0.001). Uptake of anti‐HCV treatment increased from 53.9% in 2015 to 95.0% in 2019 (p < 0.001).

Conclusions

In Spain, the prevalence of active HCV infection among PLWH at the end of 2019 was 2.2%, i.e. 90.0% lower than in 2015. Increased exposure to DAAs was probably the main reason for this sharp reduction. Despite the high coverage of treatment with direct‐acting antiviral agents, HCV‐related cirrhosis remains significant in this population.

HIV/HBV coinfection: temporal trends and patient characteristics, Spain, 2002 to 2018

Background

Recent and reliable estimates on the prevalence of coinfection with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) in Europe are lacking.

Aim

Leveraged on a study designed to assess HIV/HCV coinfection prevalence, we assessed the prevalence of HIV/HBV coinfection in Spain in 2018 and compared the results with five similar studies performed since 2002.

Methods

This cross-sectional prevalence study was carried out in 43 centres, and patients were selected using simple random sampling. The reference population comprised 40,322 patients and the sample size were 1,690 patients.

Results

The prevalence of HIV/HBV coinfection in Spain at the end of 2018 was 3.2%. The prevalence in 2002, 2009, 2015, 2016 and 2017 was 4.9%, 3.4%, 3%, 3.9% and 3%, respectively. Among the HIV/HBV-coinfected patients identified in 2018, 16.7% had cirrhosis according to transient elastography and 26.3% tested positive for antibodies against hepatitis D virus. All HIV/HBV-coinfected patients were receiving drugs with activity against HBV, and 97% of those tested for HBV DNA had an HBV DNA load < 80 IU/mL.

Conclusions

The prevalence of HIV/HBV coinfection in Spain remained stable at around 3% for a decade. Our data could facilitate the design of national programmes to control HBV infection and help identify areas of patient management that need improvement.

Synthesis of thermoelectric magnesium-silicide pastes for 3D printing, electrospinning and low-pressure spray

In this work, eco-friendly magnesium-silicide (Mg₂Si) semiconducting (n-type) thermoelectric pastes for building components concerning energy-harvesting devices through 3D printing, spray and electrospinning were synthetized and tested for the first time. The Mg₂Si fine powders were obtained through the combination of ball milling and thermal annealing under Ar atmosphere. While the latter process was crucial for obtaining the desired Mg₂Si phase, the ball milling was indispensable for homogenizing and reducing the grain size of the powders. The synthetized Mg₂Si powders exhibited a large Seebeck coefficient of ~ 487 µV/K and were blended with a polymeric solution in different mass ratios to adjust the paste viscosity to the different requirements of 3D printing, electrospinning and low-pressure spray. The materials produced in every single stage of the paste synthesis were characterized by a variety of techniques that unequivocally prove their viability for producing thermoelectric parts and components. These can certainly trigger further research and development in green thermoelectric generators (TEGs) capable of adopting any form or shape with enhanced thermoelectric properties. These green TEGs are meant to compete with common toxic materials such as Bi₂Te₃, PbTe and CoSb that have Seebeck coefficients in the range of ~ 290-700 μV/K, similar to that of the produced Mg₂Si powders and lower than that of 3D printed bulk Mg₂Si pieces, measured to be ~ 4866 μV/K. Also, their measured thermal conductivities proved to be significantly lower (~ 0.2 W/mK) than that reported for Mg₂Si (≥ 4 W/mK). However, it is herein demonstrated that such thermoelectric properties are not stable over time. Pressureless sintering proved to be indispensable, but difficultly achievable by long thermal annealing (even above 32 h) in inert atmosphere at 400 °C, at least for bulk Mg₂Si pieces constituted by a mean grain size of 2-3 μm. Hence, for overcoming this sintering challenge and become the silicide's extrusion viable in the production of bulk thermoelectric parts, alternative pressureless sintering methods will have to be further explored.

All-oral direct-acting antiviral therapy against hepatitis C virus (HCV) in human immunodeficiency virus/HCV-coinfected subjects in real-world practice: Madrid coinfection registry findings

We evaluated treatment outcomes in a prospective registry of human immunodeficiency virus/hepatitis C virus (HCV)-coinfected patients treated with interferon-free direct-acting antiviral agent-based therapy in hospitals from the region of Madrid between November 2014 and August 2016. We assessed sustained viral response at 12 weeks after completion of treatment and used multivariable logistic regression to identify predictors of treatment failure. We evaluated 2,369 patients, of whom 59.5% did not have cirrhosis, 33.9% had compensated cirrhosis, and 6.6% had decompensated cirrhosis. The predominant HCV genotypes were 1a (40.9%), 4 (22.4%), 1b (15.1%), and 3 (15.0%). Treatment regimens included sofosbuvir (SOF)/ledipasvir (61.9%), SOF plus daclatasvir (14.6%), dasabuvir plus ombitasvir/paritaprevir/ritonavir (13.2%), and other regimens (10.3%). Ribavirin was used in 30.6% of patients. Less than 1% of patients discontinued therapy owing to adverse events. The frequency of sustained viral response by intention-to-treat analysis was 92.0% (95% confidence interval, 90.9%-93.1%) overall, 93.8% (92.4%-95.0%) for no cirrhosis, 91.0% (88.8%-92.9%) for compensated cirrhosis, and 80.8% (73.7%-86.6%) for decompensated cirrhosis. The factors associated with treatment failure were male sex (adjusted odds ratio, 1.75; 95% confidence interval, 1.14-2.69), Centers for Diseases Control and Prevention category C (adjusted odds ratio, 1.65; 95% confidence interval, 1.12-2.41), a baseline cluster of differentiation 4-positive (CD4+) T-cell count <200/mm3 (adjusted odds ratio, 2.30; 95% confidence interval, 1.35-3.92), an HCV RNA load ≥800,000 IU/mL (adjusted odds ratio, 1.63; 95% confidence interval, 1.14-2.36), compensated cirrhosis (adjusted odds ratio, 1.35; 95% confidence interval, 0.96-1.89), decompensated cirrhosis (adjusted odds ratio, 2.92; 95% confidence interval, 1.76-4.87), and the use of SOF plus simeprevir, SOF plus ribavirin, and simeprevir plus daclatasvir.

CONCLUSION

In this large real-world study, direct-acting antiviral agent-based therapy was safe and highly effective in coinfected patients; predictors of failure included gender, human immunodeficiency virus-related immunosuppression, HCV RNA load, severity of liver disease, and the use of suboptimal direct-acting antiviral agent-based regimens. (Hepatology 2018;68:32-47).

Human Immunodeficiency Virus/Hepatits C Virus Coinfection in Spain: Elimination Is Feasible, but the Burden of Residual Cirrhosis Will Be Significant

Background

We assessed the prevalence of antibodies against hepatitis C virus (HCV-Abs) and active HCV infection in patients infected with human immunodeficiency virus (HIV) in Spain in 2016 and compared the results with those of similar studies performed in 2002, 2009, and 2015.

Methods

The study was performed in 43 centers during October-November 2016. The sample was estimated for an accuracy of 2% and selected by proportional allocation and simple random sampling. During 2016, criteria for therapy based on direct-acting antiviral agents (DAA) were at least significant liver fibrosis, severe extrahepatic manifestations of HCV, and high risk of HCV transmissibility.

Results

The reference population and the sample size were 38904 and 1588 patients, respectively. The prevalence of HCV-Abs in 2002, 2009, 2015, and 2016 was 60.8%, 50.2%, 37.7%, and 34.6%, respectively (P trend <.001, from 2002 to 2015). The prevalence of active HCV in 2002, 2009, 2015, and 2016 was 54.0%, 34.0%, 22.1%, and 11.7%, respectively (P trend <.001). The anti-HCV treatment uptake in 2002, 2009, 2015, and 2016 was 23.0%, 48.0%, 59.3%, and 74.7%, respectively (P trend <.001). In 2016, HCV-related cirrhosis was present in 7.6% of all HIV-infected individuals, 15.0% of patients with active HCV, and 31.5% of patients who cleared HCV after anti-HCV therapy.

Conclusions

Our findings suggest that with universal access to DAA-based therapy and continued efforts in prevention and screening, it will be possible to eliminate active HCV among HIV-infected individuals in Spain in the short term. However, the burden of HCV-related cirrhosis will continue to be significant among HIV-infected individuals.

Eradication of hepatitis C virus and non-liver-related non-acquired immune deficiency syndrome-related events in human immunodeficiency virus/hepatitis C virus coinfection

We assessed non-liver-related non-acquired immunodeficiency syndrome (AIDS)-related (NLR-NAR) events and mortality in a cohort of human immunodeficiency virus (HIV)/hepatitis C virus (HCV)-coinfected patients treated with interferon (IFN) and ribavirin (RBV), between 2000 and 2008. The censoring date was May 31, 2014. Cox regression analysis was performed to assess the adjusted hazard rate (HR) of overall death in responders and nonresponders. Fine and Gray regression analysis was conducted to determine the adjusted subhazard rate (sHR) of NLR deaths and NLR-NAR events considering death as the competing risk. The NLR-NAR events analyzed included diabetes mellitus, chronic renal failure, cardiovascular events, NLR-NAR cancer, bone events, and non-AIDS-related infections. The variables for adjustment were age, sex, past AIDS, HIV transmission category, nadir CD4⁺ T-cell count, antiretroviral therapy, HIV RNA, liver fibrosis, HCV genotype, and exposure to specific anti-HIV drugs. Of the 1,625 patients included, 592 (36%) had a sustained viral response (SVR). After a median 5-year follow-up, SVR was found to be associated with a significant decrease in the hazard of diabetes mellitus (sHR, 0.57; 95% confidence interval [CI], 0.35-0.93; P = 0.024) and decline in the hazard of chronic renal failure close to the threshold of significance (sHR, 0.43; 95% CI, 0.17-1.09; P = 0.075).

CONCLUSION

Our data suggest that eradication of HCV in coinfected patients is associated not only with a reduction in the frequency of death, HIV progression, and liver-related events, but also with a reduced hazard of diabetes mellitus and possibly of chronic renal failure. These findings argue for the prescription of HCV therapy in coinfected patients regardless of fibrosis stage. (Hepatology 2017;66:344-356).

Clinical effects of viral relapse after interferon plus ribavirin in patients co-infected with human immunodeficiency virus and hepatitis C virus

BACKGROUND & AIMS

Sustained viral response (SVR) after therapy with interferon-ribavirin (IF-RB) reduces liver-related (LR) complications and mortality in HIV/HCV-co-infected patients. Here, we assess the impact of end-of-treatment response with subsequent relapse (REL) on LR events (LR death, liver decompensation, hepatocellular carcinoma, or liver transplantation), and liver stiffness (LS) by transient elastography.

METHODS

We analyzed the GESIDA 3603 Cohort (HIV/HCV-co-infected patients treated with IF-RB in 19 centers in Spain). Response to IF-RB was categorized as SVR, REL, and no response (NR). The study started when IF-RB was stopped and ended at death or the last follow-up visit. Multivariate regression analyses were adjusted for age, sex, HIV category of transmission, CDC clinical category, nadir CD4+ cell count, HCV genotype, HCV-RNA viral load, and liver fibrosis.

RESULTS

Of 1599 patients included, response was categorized as NR in 765, REL in 250 and SVR in 584. Median follow-up was more than 4 years in each group. Taking the group of patients with NR as reference, we found that the adjusted hazard ratios (95% confidence interval) of liver-related events (liver-related death, liver decompensation, hepatocellular carcinoma, liver transplantation) for patients with REL and for patients with SVR were 0.17 (0.05; 0.50) and 0.03 (0; 0.20), respectively. We also found that SVR was followed by less liver stiffness than both REL and NR. However, REL was associated with less liver stiffness than NR.

CONCLUSIONS

Best outcomes were achieved with an SVR. However, REL was associated with less LR mortality, decompensation, and liver stiffness than NR.

Sustained virological response to interferon plus ribavirin reduces non-liver-related mortality in patients coinfected with HIV and Hepatitis C virus

BACKGROUND

Sustained virological response (SVR) after therapy with interferon plus ribavirin reduces liver-related complications and mortality in patients coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). We assessed the effect of SVR on HIV progression and mortality not related to liver disease.

METHODS

An observational cohort study including consecutive HIV/HCV-coinfected patients treated with interferon plus ribavirin between 2000 and 2008 in 19 centers in Spain.

RESULTS

Of 1599 patients, 626 (39%) had an SVR. After a median follow-up of approximately 5 years, we confirmed that failure to achieve an SVR was associated with an increased risk of liver-related events and liver-related death. We also observed higher rates of the following events in nonresponders than in responders: AIDS-defining conditions (rate per 100 person years, 0.84 [95% confidence interval (CI), .59-1.10] vs 0.29 [.10-.48]; P= .003), non-liver-related deaths (0.65 [.42-.87] vs 0.16 [.02-.30]; P = .002), and non-liver-related, non-AIDS-related deaths (0.55 [.34-.75] vs 0.16 [.02-.30]; P = .002). Cox regression analysis showed that the adjusted hazard ratios of new AIDS-defining conditions, non-liver-related deaths, and non-liver-related, non-AIDS-related deaths for nonresponders compared with responders were 1.90 (95% CI, .89-4.10; P = .095), 3.19 (1.21-8.40; P = .019), and 2.85 (1.07-7.60; P = .036), respectively.

CONCLUSIONS

Our findings suggest that eradication of HCV after therapy with interferon plus ribavirin in HIV/HCV-coinfected patients is associated not only with a reduction in liver-related events but also with a reduction in HIV progression and mortality not related to liver disease.

Evidence for epistatic gene interactions between growth factor genes in stroke outcome

BACKGROUND AND PURPOSE

Growth factors are thought to modulate neurological function in stroke recovery through effects in angiogenesis, neurogenesis, and neuroprotection.

METHODS

We tested the association of variants in the brain-derived neurotrophic factor (BDNF), fibroblast growth factor 2 (FGF2) and vascular endothelial growth factor A (VEGFA) genes, and epistatic interactions between them, with functional outcome in a sample of 546 stroke patients.

RESULTS

While none of the tested genes was independently associated with stroke outcome, two significant gene-gene interaction models were identified. One model combined one BDNF and three FGF2 markers, with a global odds ratio (OR) (95% confidence interval [CI]) of 4.15 [2.86-6.04]. The second model included one FGF2 and two VEGFA markers with a global OR [95% CI] = 2.54 [1.76-3.67].

CONCLUSIONS

The results provide evidence for gene interactions in stroke outcome, highlighting the complexity of the recovery mechanisms after a stroke event.

Effect of simultaneous use of highly active antiretroviral therapy on survival of HIV patients with tuberculosis

INTRODUCTION

The optimal timing for initiation of highly active antiretroviral therapy (HAART) in patients with AIDS and tuberculosis (TB) is an unresolved question. To assess the effect of HAART on the survival of patients with TB, we designed this study.

METHODS

We selected all HIV patients included in the COMESEM cohort with TB diagnosis after 1996. Clinical and epidemiological data were registered. We compared patients who started HAART at the diagnosis of TB [simultaneous therapy (ST)] or not. Survival was assessed by Cox analysis.

RESULTS

Among the 6934 HIV patients included in the cohort, 1217 patients had TB, 322 of them (26.5%) after 1996. At the time of TB diagnosis, 45% of them started HAART (ST). There were no differences between groups regarding basal characteristics, except for a lower viral load in ST patients. ST therapy was associated with improved survival (hazard ratio 0.38; 95% confidence interval 0.20 to 0.72, P = 0.003). By univariate analysis, survival was also associated with no endovenous drug use and a later year of TB diagnosis. After adjusting for other prognostic variables, by Cox multivariate analysis, ST remained robustly associated with improved survival (hazard ratio 0.37; 95% confidence interval 0.17 to 0.66, P = 0.001).

CONCLUSIONS

Simultaneous HAART and TB treatment in HIV patients with TB is associated with improved survival.

The changing pattern of tuberculosis and HIV co-infection in immigrants and Spaniards in the last 20 years

OBJECTIVES

To evaluate the impact of immigration on tuberculosis (TB)-HIV co-infection in Spain in a prospective cohort of HIV patients.

METHODS

Among 7761 HIV patients, we evaluated 1284 with at least one episode of TB between 1987 and 2006. Variables were compared between immigrants and Spaniards.

RESULTS

Incidence of TB decreased from 20 to five cases per 100 patient-years in 2006 (P<0.01) and was always higher in immigrants than in Spaniards. The proportion of immigrants increased, reaching almost 50% of both new cases of HIV and TB-HIV co-infection in 2006. In 34.4% of patients, TB and HIV infection were diagnosed within the same year; simultaneous diagnosis was more frequent in immigrants (83.3%vs. 16.7%, P<0.001). Mortality was associated independently with age [hazard ratio (HR) 1.03, 95% confidence interval (CI) 1.01-1.05], TB diagnosis before 1996 (HR 2.6, 95% CI 1.8-3.6), use of highly active antiretroviral treatment (HR 0.494, 95% CI 0.37-0.66) and CD4 cell count at TB diagnosis (HR 0.996, 95% CI 0.995-0.997).

CONCLUSIONS

Immigrants have a major impact on the incidence of TB in HIV patients, slowing down the decreasing trend in Spain. Simultaneous diagnosis of the co-infection in immigrants reveals a need to intensify HIV case finding in immigrants in Spain.

Economic evaluation of assistance to HIV patients in a Spanish hospital

BACKGROUND

Little is known about the global effects of HAART on the use of medical resources after the complete implementation of this therapy in Spain. This study was designed to determine the use of medical resources and the costs of health care for HIV-infected patients.

METHODS

All patients with HIV infection who came to our institution during the year 2002 were included in the study. We analyzed the global assistance data and pharmaceutical costs during the year. Costs were calculated based on a unitary cost for DRG and an officially assigned standard cost for outpatient clinic, visits to the day care unit and to the emergency room (ER), outpatient surgery, and total costs of pharmacy.

RESULTS

The total cost for HIV-related health care assistance was euro739,048. The cost related to admissions was euro150,766.60; euro8631 per first visit and euro49,199.40 per successive visit; euro5085.10 per day care unit; euro14,920 per outpatient surgery; euro7655.70 per ER visit; and euro491,342.40 per antiretroviral treatment. A significant proportion of the total outpatient assistance was given by physicians other than HIV specialists, namely, 63% of the costs attributed to the first visit and 41% per successive visit.

CONCLUSION

More than 50% of the costs of caring for HIV-infected patients are still attributed to antiretroviral therapy. Specialists other than infectious disease specialists provide a significant proportion of outpatient assistance. A method to control HIV costs is greatly needed.

Genotyping of fimbrial adhesins in Escherichia coli strains isolated from Slovak piglets suffering from diarrhea

One-hundred sixty Escherichia coli isolates obtained from piglets with diarrhea from different parts of Slovakia were examined for the presence of genes coding for F4, F5, F6 and F41 fimbrial adhesins, and hemolytic activity. According to polymerase chain reaction tests 74 (46%) E. coli isolates were positive for primers that detected genes coding for fimbrial adhesins. Of these 74 isolates, 64 were positive for genes encoding for F4+, four for F5+, five for F6+, and one for both F41+ and F5+ adhesins.

[Multicenter cohort of patients with HIV infection in the Madrid south-eastern metropolitan crown (COMESEM): basis, organization and initial results]

BACKGROUND

In order to evaluate changes related to the effect of new anti-retroviral agents and preventive programs, cohort studies of patients with HIV in our environment are needed.

METHODS

Cohort study of patients diagnosed of HIV infection in the five hospitals included in the Madrid metropolitan south-eastern crown (COMESEM), which attend a population of 1,300,000 inhabitants.

RESULTS

A total of 5,532 patients had been recruited until August 2001 (with a follow-up of 34,227 patients-year). The male/female ratio was 3/1. As for the transmission mechanism, 72.9% were parenteral drug users (PDU), 13.7% heterosexuals (HTX) and 8% of males having sex with males (MSM). The maximal figure of diagnosis per year corresponded to 1991 for PDU, 1993 for MSM and 1995 for heterosexuals. A decline in the number of diagnosed patients was observed for all groups, but MSM showed an increase in the year 2001 for the first time. Notably, among HTX, a growing and sustained trend was observed of patients not born in Spain (0% in 1993 and 50% in 2001; p < 0.001).

CONCLUSIONS

Establishing a large cohort of HIV infected patients based upon medium-sized hospitals is possible. The analysis of data derived from this cohort allows the early detection of changes in the clinical and epidemiological profile of HIV infection.

[A cost-benefit evaluation of prenatal diagnosis performed at a referral center with a population with a genetic or abnormality risk]

Prenatal diagnosis (PND) has assistencial, psychological and economical consequences; it is very important to evaluate cost effectiveness for the population. A prospective study was done (longitudinal and descriptive) on a population referred to Maternidade Dr. Alfredo da Costa, divided into two groups. Group one with PND performed on proper time and second group a PND procedure performed on a adequate time. The general characterization, indications for reference and consequences were evaluated. The conclusions are that the indications for reference were correct and the diagnosis was effective in 17% of patients. Social, economical levels and multiparity were the most important factors affecting adequate PND. However concerning the results, the termination of pregnancy was more performed on the group 1 and more abnormalities were seen on the newborns of group 2.

[Follow-up of the patient with HIV infection: a hospital task?]

OBJECTIVE

To assess how often patients with HIV infection abandon treatment.

DESIGN

Longitudinal, prospective and observational study. SITE. Out-patient Hospital Clinic.

PATIENTS AND OTHERS PARTICIPANTS

The total number of patients with HIV infection treated between September 1989 and December 1990.

INTERVENTIONS

Assessment of the level of out-patient follow-up.

MEASUREMENTS AND MAIN RESULTS

The rate of abandonment of out-patient follow-up was determined, with "abandonment" defined as unexplained non-attendance for at least two consecutive appointments. Its possible correlations with sex, age and HIV risk behaviour was calculated. 182 patients (143 men and 39 women) with an average age of 30.1 (ds 8.62) were surveyed. The abandonment rate for the sample as a whole was 44%, with no difference as to sex. However the abandonment rate was higher in the group of patients addicted to drugs (DDA) (69%) than in non-DDA (25%) or in ex-DDA patients (6.5%). These figures reached high statistical significance (p less than 0.01 and 0.001 respectively.

CONCLUSIONS

The abandonment rate of out-patient hospital follow-up by HIV-infected patients appears extremely high, especially among drug addicts (DDA).

[Spontaneous pneumothorax and Pneumocystis carinii pneumonia. Something more than a casual association?]

The association of spontaneous pneumothorax and Pneumocystis pneumonia is not frequent. The medical literature reports a ratio between 0 and 5.7%. In 18 patients admitted in our hospital, in the last two years, and diagnosed of AIDS and Pneumocystis pneumonia, we observed two cases of pneumothorax spontaneous. They represent the 11%. In one of them spontaneous pneumothorax was the first manifestation and in the other a complication of the illness. It was not possible to isolate an agent different from Pneumocystis carinii. Considering the lack of predisposition factors and the previous clinical history, we think that Pneumocystis carinii is by itself the agent responsible of this complication. In view of this possibility, spontaneous pneumothorax in a patient who belongs to an AIDS' risk group will alert the clinician to the possibility of infection with Pneumocystis carinii.

Renal handling of uric acid in patients with recurrent calcium nephrolithiasis and hyperuricosuria

Hyperuricosuria is a frequent finding in patients with recurrent calcium nephrolithiasis (RCN) that has been related to purine overingestion . The influence of diet and the renal handling of uric acid were investigated in patients with RCN to assess the pathogenic mechanism of excessive urate excretion. Among 50 patients with recurrent nephrolithiasis 42 formed renal stones containing calcium and 9 of these 42 patients demonstrated concomitant asymptomatic hyperuricosuria while on a self-selected diet. Ingestion of a purine-free diet normalized the uric acid excretion in 4 of these 9 patients. The other 5 patients showed persistent hyperuricosuria while on a purine-free diet. In order to assess a possible dysfunction in the renal handling of uric acid, pharmacological tests were undertaken in these 9 patients. Pyrazinamide administration almost completely suppressed urate excretion, excluding a presecretory reabsorption defect. Urate excretion in response to probenecid administration was decreased in 4 patients and increased in 1. This finding is in accordance with a postsecretory reabsorption defect in the former and an augmented tubular secretion of urate in the latter. This study proves that both dietary factors and tubular transport defects are involved in patients with recurrent calcium nephrolithiasis and hyperuricosuria.

Renal tubular acidosis in recurrent renal stone formers

Renal tubular acidosis (RTA) is a well-known metabolic disturbance that may promote recurrent renal stone formation. However, its incidence, screening criteria and association with other lithogenic metabolic abnormalities are not established in recurrent nephrolithiasis. 10 of 50 consecutive recurrent renal stone formers had a persistent fasting morning urinary pH above 6.0 and/or a basal plasma bicarbonate concentration below 20.0 mM. Acid and alkaline loads disclosed RTA in 3 patients: 1 patient had incomplete type-1 distal RTA in addition to hyperoxaluria; a second patient showed complete type-2 proximal RTA, hyperoxaluria and renal hypercaliuria; and a third patient had incomplete proximal RTA without any other metabolic derangement. These results reinforce the importance of RTA as an isolated metabolic abnormality among recurrent renal stone formers. In addition, RTA appears to be more commonly associated with other lithogenic metabolic derangements than has been previously suspected. The extensive metabolic protocol used in this study provides a useful tool in the diagnosis and therapeutic considerations of recurrent nephrolithiasis.