SWIFT: prospective 48-week study to evaluate efficacy and safety of switching to emtricitabine/tenofovir from lamivudine/abacavir in virologically suppressed HIV-1 infected patients on a boosted protease inhibitor containing antiretroviral regimen

BACKGROUND

In the United States, emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) is a preferred nucleoside reverse transcriptase inhibitor (NRTI) backbone with lamivudine/abacavir (3TC/ABC) as a commonly used alternative. For patients infected with human immunodeficiency virus (HIV-1) virologically suppressed on a boosted protease inhibitor (PI) + 3TC/ABC regimen, the merits of switching to FTC/TDF as the NRTI backbone are unknown.

METHODS

SWIFT was a prospective, randomized, open-label 48-week study to evaluate efficacy and safety of switching to FTC/TDF. Subjects receiving 3TC/ABC + PI + ritonavir (RTV) with HIV-1 RNA < 200 c/mL ≥3 months were randomized to continue 3TC/ABC or switch to FTC/TDF. The primary endpoint was time to loss of virologic response (TLOVR) with noninferiority measured by delta of 12%. Virologic failure (VF) was defined as confirmed rebound or the last HIV-1 RNA measurement on study drug ≥200 c/mL.

RESULTS

In total, 311 subjects were treated in this study (155 to PI + RTV + FTC/TDF, 156 to PI + RTV + 3TC/ABC). Baseline characteristics were similar between the arms: 85% male, 28% black, median age, 46 years; and median CD4 532 cells/mm(3). By TLOVR through week 48, switching to FTC/TDF was noninferior compared to continued 3TC/ABC (86.4% vs 83.3%, treatment difference 3.0% (95% confidence interval, -5.1% to 11.2%). Fewer subjects on FTC/TDF experienced VF (3 vs 11; P = .034). FTC/TDF showed greater declines in fasting low-density lipoproteins (LDL), total cholesterol (TC), and triglycerides (TG) with significant declines in LDL and TC beginning at week 12 with no TC/HDL ratio change. Switching to FTC/TDF showed improved NCEP thresholds for TC and TG and improved 10-year Framingham TC calculated scores. Decreased estimated glomerular filtration rate [corrected] (eGFR) was observed in both arms with a larger decrease in the FTC/TDF arm.

CONCLUSIONS

Switching to FTC/TDF from 3TC/ABC maintained virologic suppression, had fewer VFs, improved lipid parameters and Framingham scores but decreased eGFR. CLINICALTRIALS.GOV IDENTIFIER: NCT00724711.

Touch prep (TP) cytology as a tool for determining pulmonary parenchymal resection margin status

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Background: Accurate determination of parenchymal resection margins is critical in excision of primary and metastatic lung cancers. Complete microscopic examination of the entire margin is difficult and may not give timely results. Staple-line excision may compromise the accuracy of histologic margin exam (HME). TP offers a novel method to obtain pulmonary parenchymal margin status intraoperatively. Methods: Patients undergoing wedge resection for a known malignant lung lesion were studied prospectively. At the time of resection, the specimen stapled margin underwent TP on 3 glass slides for cytological analysis. The presence or absence of malignant cells on TP was correlated to final HME. Local recurrence and overall survival by TP and HME status were compared using logrank test. Results: Thirty specimens from 29 patients were studied between December 2002 and April 2006. Fifteen specimens (50%) were right- sided; 9/29 patients (31%) were male. Median age was 66 years (range 28 - 81). Histologies included non-small cell lung cancer (NSCLC) in 22 (73%), and metastases from colorectal cancer (4/30, 13%), sarcoma (2/20, 7%), and breast (1/30, 3%). All TP negative specimens had negative HME. TP was positive in 10 of 30 (33%) specimens, 6 of which had negative HME. These included 4 NSCLC and metastases from sarcoma (1) and colon (1). Mean margin distance was 4 ± 1.7 mm for TP/HME negative specimens, 0.5 ± 0 mm for TP/HME positive specimens, and 5 ± 1.7 mm for TP positive/HME negative patients. There was no difference in time to local recurrence between patients with positive margins by TP vs HME (18.6 and 18.63 months), or in TP and HME negative patients (30.1 and 30.6 months). Conclusion: TP analysis of lung parenchymal margins is safe and feasible. A negative TP is highly predictive of negative HME. Factors contributing to false-positive TP remain unresolved. Multi-institutional prospective studies are indicated for further characterization of this promising tool.

No significant financial relationships to disclose.

Validation of an Instrument Designed to Assess Medical Student Attitudes Toward Home Care

OBJECTIVES

To develop and validate an instrument to assess medical students' attitudes toward home care.

DESIGN

Survey administration before and following participation in a home care training program.

SETTING

Five medical schools in the United States.

PARTICIPANTS

326 third and fourth year medical students.

MEASUREMENTS

Factor analysis was performed on all posttests. Domains were tested for internal reliability (Chronbach's alpha). Interdomain correlation was tested. One-way analysis of variance (ANOVA) was used to determine whether the results for each domain differed among the five programs.

RESULTS

Using exploratory factor analysis, the original 20-item survey was revised to yield a 14-item survey consisting of four domains (general attitudes, home-based therapies, home care training, and time and reimbursement). Domain intra-item reliability ranged from 0.60 to 0.82. Interdomain correlations were found to be significant with the exception of one comparison (time and reimbursement and home care training). One-way ANOVA showed significant differences between the training programs for two of the four domains (home-based therapies and home care training). For a third domain, time and reimbursement, there was a trend toward differences across the schools (P = 0.06).

CONCLUSION

The instrument described in this paper is a reliable and valid instrument for assessing the impact of home care training on medical student attitudes across a series of important domains.

Treatment of vancomycin-resistant Enterococcus faecium infections with quinupristin/dalfopristin

Clinicians caring for patients with vancomycin-resistant Enterococcus faecium (VREF) infections face severe constraints in the selection of treatment. Quinupristin/dalfopristin (Synercid) is active in vitro against VREF, with a MIC(90) of 1.0 microg/mL. We investigated the clinical efficacy and safety of this agent in a multicenter, prospective, noncomparative, emergency-use study of 396 patients. Patients were included if they had signs and symptoms of active infection, including bacteremia of unknown origin, intra-abdominal infection, and skin and skin-structure infection, with no alternative antibiotic therapy available. The mean duration of treatment was 20 days (range, 4-40 days). The clinical response rate was 68.8% in the evaluable subset, and the overall response rate was 65.6%. The most common adverse events related to quinupristin/dalfopristin were arthralgias and myalgias. Related laboratory abnormalities were rare. In this severely ill patient population, quinupristin/dalfopristin was efficacious and demonstrated an acceptable safety profile in the treatment of VREF infection.

Lack of an effect of azithromycin on the disposition of zidovudine and dideoxyinosine in HIV-infected patients

Two studies were conducted in HIV-infected subjects to assess the potential for azithromycin to interact with zidovudine and dideoxyinosine. Both studies used 12 subjects. The zidovudine study dosed subjects with 1200 mg/day of azithromycin (n = 7) (later changed to 600 mg/day [n = 5]) for Days 8 to 21 of a 21-day course of 100 mg, five times/day of zidovudine. Subjects treated with 200 mg of dideoxyinosine twice daily for 21 days received 1200 mg of azithromycin or an equivalent amount of placebo/day for Days 8 to 21. Antiretroviral plasma and urine sampling were conducted on Days 1, 7, and 21 for zidovudine and on Days 7 and 21 for dideoxyinosine. Peripheral mononuclear cells were also collected for quantitation of phosphorylated zidovudine. Azithromycin had no significant impact on the Cmax and AUC of zidovudine, although it significantly decreased the zidovudine tmax by 44% and increased the intracellular exposure to phosphorylated zidovudine by 110%. Azithromycin had no significant effect on dideoxyinosine pharmacokinetics. Based on the results of these studies, it is concluded that azithromycin may be safely coadministered with both zidovudine and dideoxyinosine.

Acute pancreatitis as a complication of polyarteritis nodosa

CONCLUSIONS

Polyarteritis nodosa (PAN) must be considered as one of the rare causes of "idiopathic" acute necrotizing pancreatitis.

BACKGROUND

PAN is characterized by panmural inflammation of arterioles causing arteriolar ectasia, aneurysm formation, and thrombosis, resulting in organ ischemia.

METHODS

We report a case of necrotizing pancreatitis associated with segmental necrosis of the liver and spleen due to polyarteritis nodosa.

RESULTS

Five previously reported cases of documented acute pancreatitis secondary to PAN have been identified from the English literature. The mechanism through which pancreatic ischemia results in acute pancreatitis is unknown. Although limited pancreatic infarction is common in PAN, necrotizing pancreatitis is rare, and the poor overall prognosis of PAN is owing largely to other organ complications.

The effect of aging on bone mineral metabolism and bone mass in Native American women

OBJECTIVE

To examine the effect of age on mineral metabolism and bone mineral density (BMD) of the hip and spine in Native American women.

DESIGN

A cross-sectional study.

SETTING

The Sac and Fox Nation in rural Oklahoma

MEASUREMENTS

Serum measurements were made of 25 hydroxyvitamin D (25OHD), osteocalcin, and immunoreactive parathyroid hormone. Bone mineral density of the hip and spine was assessed by dual energy X-ray absorptiometry.

PARTICIPANTS

A total of 77 Native American women aged 19 to 85 years.

RESULTS

Serum 25 hydroxyvitamin D was related inversely to age (r = -0.32; P < .05) and was less than 15 ng/mL in 7% of the subjects. Serum osteocalcin was higher (P < .001) in postmenopausal than in premenopausal subjects. In postmenopausal subjects, serum osteocalcin was related to age (r = .59, P < .001). BMD was lower (P < .001) in postmenopausal than in premenopausal subjects. There was no evidence of bone loss before age 50 in either the femur or the spine. Age (r > or = -0.48, P < .001) and body mass index (BMI) (r > or = 0.41, P < .005) were independent determinants of both femoral and lumbar BMD. Serum 25OHD was a significant independent determinant of both lumbar (r = .26, P < .05) and femoral (r = .41, P < .01) BMD. Age, BMI, and serum 25OHD together accounted for 70% of the variance in BMD at these sites. The use of t scores indicated femoral bone density was higher (P < .05) in premenopausal Native American women, and lower (P < 0.05) in postmenopausal subjects, compared with white women.

CONCLUSIONS

In Native American women, there is a reduction in bone density and a sustained increase in bone turnover postmenopausally. BMI and serum 25OHD are significant determinants of BMD. Peak BMD may be higher, and the postmenopausal rate of bone loss greater, than that in white women.

Congenital coronary arteriovenous fistula: spontaneous rupture and cardiac tamponade

Congenital coronary arteriovenous fistula is an unusual, but not rare, coronary anomaly. Management of asymptomatic fistulas is controversial because of great variability in natural history. We describe an 82-year-old female patient with spontaneous rupture of a previously undetected left main coronary artery-to-pulmonary artery coronary arteriovenous fistula, with resulting hemopericardium and cardiac tamponade. Emergent surgical exploration and repair provided successful treatment.

Clinical pharmacokinetics of cidofovir in human immunodeficiency virus-infected patients

The pharmacokinetics of cidofovir (HPMPC; (S)-1-[3-hydroxy-2-(phosphonylmethoxy)propyl]cytosine) were examined at five dose levels in three phase I/II studies in a total of 42 human immunodeficiency virus-infected patients (with or without asymptomatic cytomegalovirus infection). Levels of cidofovir in serum following intravenous infusion were dose proportional over the dose range of 1.0 to 10.0 mg/kg of body weight and declined biexponentially with an overall mean +/- standard deviation terminal half-life of 2.6 +/- 1.2 h (n = 25). Approximately 90% of the intravenous dose was recovered unchanged in the urine in 24 h. The overall mean +/- standard deviation total clearance of the drug from serum (148 +/- 25 ml/h/kg; n = 25) approximated renal clearance (129 +/- 42 ml/h/kg; n = 25), which was significantly higher (P < 0.001) than the baseline creatinine clearance in the same patients (83 +/- 21 ml/h/kg; n = 12). These data indicate that active tubular secretion played a significant role in the clearance of cidofovir. The steady-state volume of distribution of cidofovir was approximately 500 ml/kg, suggesting that the drug was distributed in total body water. Repeated dosing with cidofovir at 3.0 and 10.0 mg/kg/week did not alter the pharmacokinetics of the drug. Concomitant administration of intravenous cidofovir and oral probenecid to hydrated patients had no significant effect on the pharmacokinetics of cidofovir at a 3.0-mg/kg dose. At higher cidofovir doses, probenecid appeared to block tubular secretion of cidofovir and reduce its renal clearance to a level approaching glomerular filtration.

(S)-1-[3-hydroxy-2-(phosphonylmethoxy)propyl]cytosine (cidofovir): results of a phase I/II study of a novel antiviral nucleotide analogue

Cidofovir, (S)-1-[3-hydroxy-2-(phosphonylmethoxy)propyl]cytosine, is a novel antiviral nucleotide analogue with potent in vitro and in vivo activity against cytomegalovirus (CMV) and other herpesviruses. Thirty-one human immunodeficiency virus-seropositive patients with asymptomatic CMV excretion were evaluated in a phase I/II study with 2 regimens of cidofovir: cidofovir alone at doses of 0.5, 1.0, 3.0, or 10.0 mg/kg/week (20 patients) and cidofovir at 3.0, 5.0, or 7.5 mg/kg with concomitant oral probenecid, saline prehydration, extended dosing intervals, and drug interruption for proteinuria (19 patients). Prolonged and dose-dependent anti-CMV effect was observed with all cidofovir regimens > or = 3.0 mg/kg. The dose-limiting toxicity of cidofovir was dose- and schedule-dependent nephrotoxicity. Four of 20 patients had serum creatinine levels > or = 2.0 mg/dL after a mean cumulative exposure of 14.8 mg/kg cidofovir alone; however, none of 19 patients receiving the modified regimen had elevated creatinine (mean cidofovir exposure, 32.2 mg/kg). The clinical efficacy of cidofovir and its potential for cumulative nephrotoxicity needs further study in patients with end-organ CMV disease.

Homeless women, disaffiliation and social agencies

Homeless individuals have limited social support systems. Not clearly defined, however, is the relationship between homelessness, gender, and social agencies. In our study 102 homeless individuals were interviewed in shelters. This included administration of the SADS and the subject's rating their perceived level of support from friends, family and social agencies. Significant findings in the analysis showed a higher level of perceived support by males than by females (p < 0.05). More precisely, this was true in the area of support from social agencies, where females rated support from these organizations as significantly lower than did males (p < 0.05). The findings were unchanged when age, presence of psychiatric illness or length of time homeless were factored in. Important implications for public policy are clear since existing social service agencies working with the homeless are less likely to be perceived as supportive by females than by males.

Ceftizoxime versus vancomycin and gentamicin in neurosurgical prophylaxis: a randomized, prospective, blinded clinical study

In a prospective, randomized, blinded study, 826 patients undergoing clean neurosurgical procedures received single intravenous doses of ceftizoxime (2 g) (n = 422) or a combination of vancomycin (1 g) and gentamicin (80 mg) (n = 404) 1 hour before an incision was made. Patients with infected or contaminated wounds and those receiving shunts or other implants were excluded. Primary wound infections occurred within 30 days in five patients in each group and were most common after spinal surgery and procedures through previous incisions. Secondary infections (pneumonias, urinary tract infections, and intravenous line-related bacteremia) occurred in 24 patients in the ceftizoxime group and 25 in the vancomycin/gentamicin group. The infection rates after transsphenoidal procedures (n = 129) were remarkably low in both groups. Ceftizoxime caused no adverse drug reactions, but six patients in the vancomycin/gentamicin group had clinically significant infusion-related hypotension or flushing. Placement of a temporary external drain, use of an operating microscope, preoperative steroids, and diabetes were not associated with increased infection rates. Analysis of routinely encountered ventricular cerebrospinal fluid and simultaneously obtained peripheral blood showed low but detectable levels of all three antibiotics within 2 hours; only ceftizoxime, however, achieved cerebrospinal fluid levels sufficient to inhibit the staphylococcus and Gram-negative bacilli most often associated with postneurosurgical infections. We conclude that ceftizoxime is as effective as vancomycin and gentamicin in neurosurgical prophylaxis but is less toxic and penetrates cerebrospinal fluid better.

Comparative study of bioavailabilities and pharmacokinetics of clindamycin in healthy volunteers and patients with AIDS

The absolute oral bioavailability and pharmacokinetics of clindamycin administered to 16 healthy volunteers and 16 patients with AIDS were compared. Clindamycin was given intravenously (i.v.) (Cleocin phosphate) at a dose of 600 mg as a 25-min infusion and orally (Cleocin hydrochloride) by use of a crossover design in both study groups. Plasma samples were analyzed by gas-liquid chromatography. Plasma drug clearance and volume of distribution at the steady state following the i.v. dose differed between study groups. The clearances were 0.27 +/- 0.06 liter/h/kg in healthy volunteers and 0.21 +/- 0.06 liter/h/kg in AIDS patients (P = 0.014; Mann-Whitney U test); the volumes of distribution at the steady state were 0.79 +/- 0.13 and 0.66 +/- 0.12 liter/kg in healthy volunteers and AIDS patients, respectively (P = 0.005). The elimination half-life did not differ between the two groups. The bioavailability of clindamycin capsules in AIDS patients was approximately 1.5 times that in healthy volunteers (0.53 +/- 0.14 versus 0.75 +/- 0.20; P = 0.002). Peak concentrations following the oral dose were higher in AIDS patients as well (7.7 +/- 2.5 versus 5.3 +/- 1.0 mg/liter; P = 0.0008). Three AIDS patients experienced severe diarrhea following the oral dose; four patients had mild diarrhea following the i.v. dose. No adverse effects were reported by the healthy volunteers. The pharmacokinetic parameters observed in this study for AIDS patients may be useful for the consideration of clindamycin dosage regimens in patients treated for toxoplasmic encephalitis. These findings suggest that the effect of AIDS on drug disposition deserves further investigation, particularly for orally administered drugs.

Luetic endolymphatic hydrops: diagnosis and treatment

Luetic endolymphatic hydrops (LEH) is an effectively treatable disorder that requires astute clinical judgment to suspect, confirm, and treat. We provide a review of the literature as well as recommendations regarding the clinical management of LEH with discussion of several illustrative cases. We also give an overview of laboratory testing for the diagnosis and monitoring of the infectious process. Ultimately, the control of the otologic symptoms in LEH requires acumen on the part of the clinician.

Pilot trial of selective decontamination for prevention of bacterial infection in an intensive care unit

Selective decontamination of the oropharynx and gastrointestinal tract with nonabsorbable antimicrobials and sucralfate, a stress ulcer prophylactic that maintains the normal gastric acid bacterial barrier, were compared for prevention of pneumonia in a cardiac surgery intensive care unit. Over 8 months, 51 patients received selective decontamination and 56 received sucralfate. The selective decontamination regimen included polymyxin, gentamicin, and nystatin given as an oral paste and as a solution; patients also received standard antacid or histamine2 blocker stress ulcer prophylaxis. Patients in the selective decontamination group had significantly less colonization of the oropharynx and stomach by gram-negative bacilli (12% vs. 55%, P less than .001), significantly fewer infections due to gram-negative bacilli (6% vs. 20%, P = .02), and fewer infections overall (12% vs. 27%, P = .04). There was one episode of pneumonia in the selective decontamination group and five in the sucralfate group. Mortality and length of stay did not differ between the groups, but those receiving selective decontamination had less than one-third as many days of systemic antibiotic therapy with no increase in colonization or infection with resistant gram-negative bacilli. Thus, selective decontamination appeared to reduce both extrapulmonary and pulmonary infections.

Parental communication and psychological distress in children of Holocaust survivors: a comparison between the U.S. and Israel

To determine how the children of Holocaust survivors in Israel and the U.S. differ on measures of parental communication and psychological distress, we performed a comparative study on 140 subjects in the U.S. and 54 in Israel using a written questionnaire. Respondents in Israel reported more communication by their parents, but also a higher level of demoralization; this may be due to more demoralization among the general population. In both populations, parents' general communication correlated negatively with anxiety, depression and demoralization and positively with guilt. Parents' Holocaust communication resulted in similar findings; however, in Israel only a negative correlation with demoralization reached significance. Parental communication about the Holocaust thus seems to be of less importance in Israel in determining the children's psychological outcome. This may be due to a greater role by Israeli society in forming children's perception of the Holocaust.

Gender differences in the perception and utilization of social support: theoretical perspectives and an empirical test

The authors contend that women are the more supportive, nurturing and affectively-connected sex. They argue that these gender differences result from socialization experiences which may be modified by social and occupational roles. Theoretical perspectives and research addressing this proposition are reviewed. Empirical data on support-eliciting and support-providing behaviors in a cohort of medical students are then provided to test their thesis. The data suggest that women have developed a greater sensitivity to the needs of themselves and others, leading to a greater capacity to provide support and a greater dependence upon social support for psychological well-being. Personality and developmental factors that may account for these differences are examined. The implications of these findings for gender differences in mental health are discussed.

Conceptions and misconceptions of menstruation

College women were asked a series of open-ended questions about their conceptions of menstruation prior to menarche as part of a retrospective study. Their responses were rated as indicating correct information, misinformation, or lack of information. A conceptual analysis of these descriptive data reveals some of the emotional and cognitive limitations of pre-adolescence that lead ostensibly well-informed girls to harbor misconceptions about menstruation. Based on this conceptual analysis, a revised approach to menstrual education is suggested.

Coping and depression. The relative contribution of internal and external resources during a life cycle transition

This study addresses two questions relevant to psychiatric epidemiological models of the stress-distress relationship: Are personality and social support resources independent phenomena or highly correlated? and What are the relative contributions of these two types of resources in protecting against the development of depressive symptomatology? A cohort of beginning medical students was administered self-report questionnaires measuring social supports, locus of control, interpersonal dependency, and depressive symptomatology. On the basis of correlation and regression analysis, the data show that the personality characteristics more strongly predict depressive symptomatology than do social supports, and that social supports are unrelated to locus of control but directly correlated with interpersonal dependency. The authors discuss these findings in the context of a life cycle transition.

Transmural gradients in myocardial gas tensions in regionally ischemic canine left ventricle

Previous studies from this laboratory have demonstrated the usefulness of myocardial gas tensions as measured by mass spectrometry for the quantitative assessment of regional myocardial ischemia (Khuri et al., 1975a). Progressive increases in myocardial carbon dioxide tensions were noted when progressive reduction in coronary blood flow was created by means of a variable constrictor. The present study was designed to determine if changes in myocardial oxygen and carbon dioxide tension were greater in deep, compared to more superficial, myocardial layers. In eight anesthetized dogs, progressive reduction in circumflex coronary flow was associated with a progressive reduction in myocardial oxygen tension and a progressive increase in myocardial carbon dioxide tension and intramyocardial ST-segment voltage. Evidence of a transmural gradient in the severity of ischemia was present at all degrees of flow reduction. These results confirm the findings of previous metabolic studies, which demonstrated gradients in lactate and high-energy phosphates. Myocardial carbon dioxide tension, which can be monitored continuously by mass spectrometry, would appear to provide a useful means of quantitatively assessing changes in regional myocardial metabolism.