No neurocognitive advantage for immediate antiretroviral treatment in adults with greater than 500 CD4+ T-cell counts

OBJECTIVE

To compare the effect of immediate versus deferred antiretroviral treatment (ART) on neuropsychological test performance in treatment-naive HIV-positive adults with more than 500 CD4 cells/μl.

DESIGN

Randomized trial.

METHODS

The START parent study randomized participants to commence immediate versus deferred ART until CD4 less than 350 cells/μl. The START Neurology substudy used eight neuropsychological tests, at baseline, months 4, 8, 12 and annually, to compare groups for changes in test performance. Test results were internally standardized to z-scores. The primary outcome was the average of the eight test z-scores (QNPZ-8). Mean changes in QNPZ-8 from baseline were compared by intent-to-treat using longitudinal mixed models. Changes from baseline to specific time points were compared using ANCOVA models.

RESULTS

The 592 participants had a median age of 34 years; median baseline CD4 count was 629 cells/μl; the mean follow-up was 3.4 years. ART was used for 94 and 32% of accrued person-years in the immediate and deferred groups, respectively. There was no difference between the immediate and deferred ART groups in QNPZ-8 change through follow-up [-0.018 (95% CI -0.062 to 0.027, P = 0.44)], or at any visit. However, QNPZ-8 scores increased in both arms during the first year, by 0.22 and 0.24, respectively (P < 0.001 for increase from baseline).

CONCLUSION

We observed substantial improvement in neurocognitive test performance during the first year in both study arms, underlining the importance of using a control group in studies assessing neurocognitive performance over time. Immediate ART neither benefitted nor harmed neurocognitive performance in individuals with CD4 cell counts above 500 cells/μl.

Possible Role of Pseudoephedrine and Other Over-the-Counter Cold Medications in the Deaths of Very Young Children

The Philadelphia Medical Examiners Office has reported a series of 15 deaths between February 1999 and June 2005 of infants and toddlers 16 months and younger in which drugs commonly found in over-the-counter (OTC) cold medications were present. A total of 10 different drugs were detected: pseudoephedrine, dextromethorphan, acetaminophen, brompheniramine, carbinoxamine, chlorpheniramine, ethanol, doxylamine and the anticonvulsants, phenobarbital, and phenytoin. The drugs were confirmed and quantified by gas chromatography (GC)-mass spectrometry, with the exception of ethanol, which was analyzed by headspace GC and of phenobarbital and phenytoin that were quantified by GC with a nitrogen phosphorus detector. The most predominant drug was pseudoephedrine, which was found in all of the cases (blood concentration, n=14, range=0.10-17.0 mg/L, mean=3.34 mg/L) and was the sole drug detected in three cases. Acetaminophen was detected in blood from each of the five cases with sufficient sample. Other drugs (with frequency of detection) were dextromethorphan (five cases), carbinoxamine (four cases), chlorpheniramine (two cases) and brompheniramine, doxylamine, and ethanol (one case each). In the majority of the cases, toxicity from drugs found in easily available OTC medications was listed either as the direct cause of death or as a contributory factor. The manner of death was determined to be natural in only two of the cases. This postmortem study supports previous evidence that the administration of OTC cold medications to infants may, under some circumstances, be an unsafe practice and in some cases may even be fatal. The treating physicians and the general public need to be made more aware of the dangers of using OTC cold medications to treat very young children so that these types of tragedies might be avoided.

Changing demographics and pathology of nonmelanoma skin cancer in the last 30 years

BACKGROUND

Nonmelanoma skin cancer is a common and important public health concern. Few long-term demographic studies to evaluate potential changes in the clinical or pathologic attributes of theses lesions have been initiated.

DESIGN

A computer-based archival search of nonmelanoma skin cancer (NMSC) diagnosed in 1972 and 2001 at a large VA medical center was examined with accompanying glass slides. The NMSC consisted of basal cell carcinoma (BCC), invasive squamous cell carcinoma (SCC) and squamous cell carcinoma in situ (SIS). Pathologic attributes examined included the histologic type of BCC (nodular, superficial, infiltrating), and histologic grade of SCC. Demographic features included age, and location. As the majority of patients were men, women were excluded from the study. The results were tabulated and statistically evaluated by the Students' t-test.

RESULTS

A total of 831 cases of NMSC diagnosed in 809 patients in 1972 compared to 1,712 cases in 1,011 patients in 2001. BCC accounted for 45%, SIS 23%, and SCC 32% in 1972 compared to 34% BCC (P = .04), 38% SIS (P = .01), and 28% SCC (P > .05) in 2001. Histologic subtypes of BCC included nodular accounted for 45%, superficial 37% and infiltrating 7% in 1972 compared to 35% (P = .05), 46% (P > .05) and 19% (P = .01) in 2001. Among SCC, 79% were well differentiated with 13% moderate and 7% poorly differentiated in 1972 compared with 82% (P > .05), 10% (P >.05), and 8% (P > .05)in 2001. The average age of patients in 1972 was 76.2 and 64.1 in 2001 (P = .02). The most common locations in 1972 are head and neck (H&N) (54%), extremities (24%); 2001 H&N (50%) and extremities (32%, P = .05).

CONCLUSIONS

The data would suggest that NMSC is being diagnosed at a younger age and more commonly on the extremities in Veteran's than in the past. The relative proportion of SIS and of superficial and infiltrating BCC is also increasing.

Littoral cell angiomatosis with poorly differentiated adenocarcinoma of the lung

We report on a 64-year-old male United States Navy Veteran of World War II, one of two identical twins, diagnosed with littoral cell angiomatosis of the spleen, liver, and lymph nodes, later found to have a massive poorly differentiated adenocarcinoma involving the mediastinum, adjoining lung, and sternum with widespread metastases. Herein we include our findings at autopsy, pertinent immunohistochemical studies, and a review of the literature pertaining to littoral cell angiomatosis with comment on its association with visceral malignancies.

Histomorphologic and immunophenotypic analysis of fibrofolliculomas and trichodiscomas in Birt-Hogg-Dube syndrome and sporadic disease

BACKGROUND

Fibrofolliculomas and trichodiscomas are benign dermal neoplasms that likely derive from the mantle of the hair follicle and can occur sporadically or in association with Birt-Hogg-Dube syndrome (BHDS). Little is known about the pathogenesis and immunophenotypic properties of these entities.

METHODS

We investigated the histomorphologic and immnophenotypic properties of 15 fibrofolliculomas and trichodiscomas in two patients with BHDS and eight with sporadic disease.

RESULTS

We found the following: (1) fibrofolliculomas and trichodiscomas occurring in the setting of BHDS show microscopically contiguous histomorphologic features as compared to those occurring sporadically; (2) the immunophenotypic characteristics of syndromic-associated and sporadic types are identical and consist of (3) perifollicular vimentin (+), CD34 (+) and Factor XIII (-) spindle cells.

CONCLUSIONS

Despite subtle histomorphologic differences, trichodiscomas and fibrofolliculomas are immunophenotypically similar, and are thus likely derived from a similar histogenic precursor. Given the previously reported CD34 (+) immunophenotype of the hair mantle, our findings would support an origin of these lesions from the mantle of the hair follicle. The proliferation of CD34 (+) spindle cells seen in conjunction with these lesions should not be confused with other CD34 (+) dermal entities.

ARDS after pulmonary contusion: accurate measurement of contusion volume identifies high-risk patients

BACKGROUND

The pathophysiology of pulmonary contusion (PC) is poorly understood, and only minimal advances have been made in management of this entity over the past 20 years. Improvement in understanding of PC has been hindered by the fact that there has been no accurate way to quantitate the amount of pulmonary injury. With this project, we examine a method of accurately measuring degree of PC by quantifying contusion volume relative to pulmonary function and outcome.

METHODS

Patients with PC from isolated chest trauma who had admission chest computed tomographic scan were identified from the registry of a Level I trauma center over a 1.5-year period. Subsequently, prospective data on all patients admitted to the intensive care unit with PC during a 5-month period were collected and added to the retrospective database. Using computer-generated three-dimensional reconstruction from admission chest computed tomographic scan, contusion volume was measured and expressed as a percentage of total lung volume. Admission pulmonary function variables (Pao2/FiO2, static compliance), injury descriptors (chest Abbreviated Injury Score, Injury Severity Score, injury distribution), and indicators of degree of shock (admission systolic blood pressure, admission base deficit) were documented. Outcomes included maximum positive end-expiratory pressure, ventilator days, pneumonia, and acute respiratory distress syndrome (ARDS).

RESULTS

Forty-nine patients with PC (35 bilateral) were identified. The average severity of contusion was 18% (range, 5-55%). Patients were classified using contusion volume as severe PC (> or =20%, n = 17) and moderate PC (< 20%, n = 32). Injury Severity Score was similar in the severe and moderate groups (23.3 vs. 26.5, p = 0.33), as were admission Glasgow Coma Scale score (12 vs. 13, p = 0.30), admission blood pressure (131 vs. 129 mm Hg, p = 0.90), and admission Pao2/Fio2 (197 vs. 255, p = 0.14). However, there was a much higher rate of ARDS in the severe group as compared with the moderate group (82% vs. 22%, p < 0.001). There was a trend toward higher pneumonia rate in the severe group, with 50% of patients in the severe group developing pneumonia as compared with 28% in the moderate group (p = 0.20).

CONCLUSION

Extent of contusion volumes measured using three-dimensional reconstruction allows identification of patients at high risk of pulmonary dysfunction as characterized by development of ARDS. This method of measurement may provide a useful tool for the further study of PC as well as for the identification of patients at high risk of complications at whom future advances in therapy may be directed.