Site-Level Comprehensiveness of Care Is Associated with Individual Clinical Retention Among Adults Living with HIV in International Epidemiology Databases to Evaluate AIDS, a Global HIV Cohort Collaboration, 2000-2016

Retention in care (RIC) reduces HIV transmission and associated morbidity and mortality. We examined whether delivery of comprehensive services influenced individual RIC within the International epidemiology Databases to Evaluate AIDS (IeDEA) network. We collected site data through IeDEA assessments 1.0 (2000-2009) and 2.0 (2010-2016). Each site received a comprehensiveness score for service availability (1 = present, 0 = absent), with tallies ranging from 0 to 7. We obtained individual-level cohort data for adults with at least one visit from 2000 to 2016 at sites responding to either assessment. Person-time was recorded annually, with RIC defined as completing two visits at least 90 days apart in each calendar year. Multivariable modified Poisson regression clustered by site yielded risk ratios and predicted probabilities for individual RIC by comprehensiveness. Among 347,060 individuals in care at 122 sites with 1,619,558 person-years of follow-up, 69.8% of person-time was retained in care, varying by region from 53.8% (Asia-Pacific) to 82.7% (East Africa); RIC improved by about 2% per year from 2000 to 2016 (p = 0.012). Every site provided CD4+ count testing, and >90% of individuals received care at sites that provided combination antiretroviral therapy adherence measures, prevention of mother-to-child transmission, tuberculosis screening, HIV-related prevention, and community tracing services. In adjusted models, individuals at sites with more comprehensive services had higher probabilities of RIC (0.71, 0.74, and 0.83 for scores 5, 6, and 7, respectively; p = 0.019). Within IeDEA, greater site-level comprehensiveness of services was associated with improved individual RIC. Much work remains in exploring this relationship, which may inform HIV clinical practice and health systems planning.

Aging with HIV: what effect on mortality and loss to follow-up in the course of antiretroviral therapy? The IeDEA West Africa Cohort Collaboration

Background

Reporting mortality and lost to follow-up (LTFU) by age is essential as older HIV-positive patients might be at risk of long-term effects of living with HIV and/or taking antiretroviral therapy (ART). As age effects might not be linear and might impact HIV outcomes in the oldest more severely, people living with HIV (PLHIV) aged 50-59 years and PLHIV aged >60 years were considered separately.

Setting

Seventeen adult HIV/AIDS clinics spread over nine countries in West Africa.

Methods

Data were collected within the International Epidemiological Databases to Evaluate AIDS West Africa Collaboration. ART-naïve PLHIV-1 adults aged >16 years initiating ART and attending ≥2 clinic visits were included (N=73,525). Age was divided into five groups: 16-29/30-39/40-49/50-59/≥60 years. The age effect on mortality and LTFU was evaluated with Kaplan-Meier curves and multivariable Cox proportional hazard regressions.

Results

At month 36, 5.9% of the patients had died and 47.3% were LTFU. Patients aged ≥60 (N=1,736) and between 50-59 years old (N=6,792) had an increased risk of death in the first 36 months on ART (adjusted hazard ratio=1.66; 95% CI: 1.36-2.03 and adjusted hazard ratio=1.31; 95% CI: 1.15-1.49, respectively; reference: <30 years old). Patients ≥60 years old tend to be more often LTFU.

Conclusion

The oldest PLHIV presented the poorest outcomes, suggesting that the PLHIV aged >50 years old should not be considered as a unique group irrespective of their age. Tailored programs focusing on improving the care services for older PLHIV in Sub-Saharan Africa are clearly needed to improve basic program outcomes.

Twenty-Year Evolution of Hepatitis B Virus and Human Immunodeficiency Virus Prevalence and Incidence in Voluntary Blood Donors in Côte d'Ivoire

Background

Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) share common risk factors. The parallel description of their frequency over time may help capture their similarities and differences.

Methods

Using data from the National Transfusion Center of Abidjan, we estimated the following over a 20-year period: (1) the prevalence of HIV and hepatitis B surface antigen (HBsAg) positivity at first contact; and (2) the incidence of HIV and HBsAg seroconversion in negative first-time blood donors.

Results

Between 1992 and 2012, 422319 donors (men [M] = 74%) provided 1063825 blood donations. For first-time donors, HIV prevalence decreased from 7.1% (M = 5.9%, women [W] =11.0%) in 1992-1994 to 1.1% (M = 0.8%, W = 2.0%) in 2010-2012. Prevalence of HBsAg positivity remained stable at 10.8% (M = 11.7%, W = 7.3%) in 1992-1994 to 11.1% (M = 12.5%, W = 7.1%) in 2010-2012. Among regular donors (N = 129256), the incidence of becoming HIV or HBsAg positive, respectively, decreased from 4.9 per 100 (M = 4.5, W = 8.6) and 7.3 per 100 person-years (M = 7.8, W = 2.3) in 1992-1994 to 0.07 (M = 0.06, W = 0.11) and 0.2 per 100 person-years (M = 0.2, W = 0.2) in 2010-2012.

Conclusions

Human immunodeficiency virus prevalence and incidence decreased dramatically over time, whereas HBV prevalence remained stable. Incidence of HBsAg seroconversion, although decreasing, still reached unexpected levels, suggesting that the risk of HBV infection in adults may be higher than expected. Hepatitis B surface antigen-negative blood-donors should be offered HBV vaccination.

Global Trends in CD4 Cell Count at the Start of Antiretroviral Therapy: Collaborative Study of Treatment Programs

Background

Early initiation of combination antiretroviral therapy (cART), at higher CD4 cell counts, prevents disease progression and reduces sexual transmission of human immunodeficiency virus (HIV). We describe the temporal trends in CD4 cell counts at the start of cART in adults from low-income, lower-middle-income, upper-middle-income, and high-income countries (LICs, LMICs, UMICs, and HICs, respectively).

Methods

We included HIV-infected individuals aged ≥16 years who started cART between 2002 and 2015 in a clinic participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) or the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE). Missing CD4 cell counts at the start of cART were estimated through multiple imputation. Weighted mixed-effect models were used to smooth trends in median CD4 cell counts.

Results

A total of 951855 adults from 16 LICs, 11 LMICs, 9 UMICs, and 19 HICs were included. Overall, the modeled median CD4 cell count at the start of cART increased from 2002 to 2015, from 78/µL (95% confidence interval, 58-104/µL) to 287/µL (250-328/µL) in LICs, from 99/µL (71-140/µL) to 234/µL (192-285/µL) in LMICs, from 71/µL (49-104/µL) to 311/µL (255-379/µL) in UMICs, and from 161/µL (143-181/µL) to 327/µL (286-372/µL) in HICs. In LICs, LMICs, and UMICs, the increase was more pronounced in women; in HICs, the opposite was observed.

Conclusions

Median CD4 cell counts at the start of cART increased in all income groups, but generally remained below 350/μL in 2015. Substantial additional efforts and resources are required to achieve earlier diagnosis, linkage to care, and initiation of cART.

Severe morbidity after antiretroviral (ART) initiation: active surveillance in HIV care programs, the IeDEA West Africa collaboration

Background

The causes of severe morbidity in health facilities implementing Antiretroviral Treatment (ART) programmes are poorly documented in sub-Saharan Africa. We aimed to describe severe morbidity among HIV-infected patients after ART initiation, based on data from an active surveillance system established within a network of specialized care facilities in West African cities.

Methods

Within the International epidemiological Database to Evaluate AIDS (IeDEA) - West Africa collaboration, we conducted a prospective, multicenter data collection that involved two facilities in Abidjan, Côte d’Ivoire and one in Cotonou, Benin. Among HIV-infected adults receiving ART, events were recorded using a standardized form. A simple case-definition of severe morbidity (death, hospitalization, fever > 38°5C, Karnofsky index < 70%) was used at any patient contact point. Then a physician confirmed and classified the event as WHO stage 3 or 4 according to the WHO clinical classification or as degree 3 or 4 of the ANRS scale.

Results

From December 2009 to December 2011, 978 adults (71% women, median age 39 years) presented with 1449 severe events. The main diagnoses were: non-AIDS-defining infections (33%), AIDS-defining illnesses (33%), suspected adverse drug reactions (7%), other illnesses (4%) and syndromic diagnoses (16%). The most common specific diagnoses were: malaria (25%), pneumonia (13%) and tuberculosis (8%). The diagnoses were reported as syndromic in one out of five events recorded during this study.

Conclusions

This study highlights the ongoing importance of conventional infectious diseases among severe morbid events occurring in patients on ART in ambulatory HIV care facilities in West Africa. Meanwhile, additional studies are needed due to the undiagnosed aspect of severe morbidity in substantial proportion.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-0910-3) contains supplementary material, which is available to authorized users.

Incidence of serious morbidity in HIV-infected adults on antiretroviral therapy in a West African care centre, 2003-2008

Background

In resource-limited settings, scaling-up antiretroviral treatment (ART) has required the involvement of decentralized health facilities with limited equipment. We estimated the incidence of serious morbidity among HIV-infected adults receiving ART in one of these HIV routine care center in sub-Saharan Africa.

Methods

We conducted a prospective study at the Centre Medical de Suivi des Donneurs de Sang (CMSDS), which is affiliated with the National Centre for Blood Transfusion in Abidjan, Côte d’Ivoire. Adult patients infected with HIV-1 or HIV-1/HIV-2 who initiated ART between January 2003 and December 2008 were eligible for the study. Standardized clinical data were collected at each visit. Serious morbidity was defined as a new episode of malaria, WHO stage 3–4 event, ANRS grade 3–4 adverse event, or any event leading to death or to hospitalization.

Results

1008 adults, 67% women, with a median age of 35 years, and a median pre-ART CD4 count of 186/mm³ started ART and were followed for a median of 17.3 months. The overall incidences of loss to follow-up, death, and attrition were 6.2/100 person-years (PY) [95% CI 5.1-7.2], 2.3/100 PY [95% CI 1.6-2.9], and 8.1/100 PY [95% CI 7.0-9.4], respectively. The incidence of first serious event was 11.5/100 PY overall, 15.9/100 PY within the first year and 8.3/100 PY thereafter. The most frequently documented specific diagnoses were malaria, tuberculosis, bacterial septicemia and bacterial pneumonia.

Conclusion

Among HIV-infected adults followed in routine conditions in a West African primary care clinic, we recorded a high incidence of serious morbidity during the first year on ART. Providing care centers with diagnostic tools and standardizing data collection are necessary steps to improve the quality of care in primary care facilities in sub-Saharan Africa.

AIDS and non-AIDS morbidity and mortality across the spectrum of CD4 cell counts in HIV-infected adults before starting antiretroviral therapy in Cote d'Ivoire

BACKGROUND

In Western Europe, North America, and Australia, large cohort collaborations have been able to estimate the short-term CD4 cell count-specific risk of AIDS or death in untreated human immunodeficiency virus (HIV)-infected adults with high CD4 cell counts. In sub-Saharan Africa, these CD4 cell count-specific estimates are scarce.

METHODS

From 1996 through 2006, we followed up 2 research cohorts of HIV-infected adults in Côte d'Ivoire. This included follow-up off antiretroviral therapy (ART) across the entire spectrum of CD4 cell counts before the ART era, and only in patients with CD4 cell counts >200  cells/μL once ART became available. Data were censored at ART initiation. We modeled the CD4 cell count decrease using an adjusted linear mixed model. CD4 cell count-specific rates of events were obtained by dividing the number of first events occurring in a given CD4 cell count stratum by the time spent in that stratum.

RESULTS

Eight hundred sixty patients were followed off ART over 2789 person-years (PY). In the ≥650, 500-649, 350-499, 200-349, 100-199, 50-99, and 0-49  cells/μL CD4 cell count strata, the rates of AIDS or death were 0.9, 1.7, 3.7, 10.4, 30.9, 60.8, and 99.9 events per 100 PY, respectively. In patients with CD4 cell counts ≥200 CD4  cells/μL, the most frequent AIDS-defining disease was tuberculosis (decreasing from 4.0 to 0.6 events per 100 PY for 200-349 and ≥650 cells/μL, respectively), and the most frequent HIV non-AIDS severe diseases were visceral bacterial diseases (decreasing from 9.1 to 3.6 events per 100 PY).

CONCLUSIONS

Rates of AIDS or death, tuberculosis, and invasive bacterial diseases are substantial in patients with CD4 cell counts ≥200 cells/μL. Tuberculosis and bacterial diseases should be the most important outcomes in future trials of early ART in sub-Saharan Africa.

Short communication: Severe symptomatic hyperlactatemia among HIV type 1-infected adults on antiretroviral therapy in Côte d'Ivoire

Stavudine is no longer recommended for use in first-line antiretroviral therapy (ART), but it remains in high demand worldwide because it is affordable. We report the clinical presentation and incidence of severe hyperlactatemia (SL) in HIV-infected adults who initiated ART between April 2005 and May 2009 in Côte d'Ivoire, West Africa. In a prospective cohort study at the HIV care center affiliated with the National Centre for Blood Transfusion, we used standardized forms to record baseline and follow-up data. We measured serum lactate levels for all adults on ART who showed signs of hyperlactatemia. SL was defined as serum lactate >2.5 mmol/liter. Overall, 806 adults initiated ART. Among the 591 patients (73%) on stavudine-containing regimens, 394 were women (67%); the median pre-ART CD4 count was 150/mm3 and the median body mass index was 20.9 kg/m2. These patients were followed for a median of 28 months. We detected SL only among patients taking stavudine. The incidence of SL was 0.55/100 person-years (PY) (95% CI 0.47-0.63) overall and 0.85/100 PY among women (95% CI 0.75-0.95). Among the eight patients with SL, 100% lost >9% of body weight before diagnosis, 100% had serum lactate >4 mmol/liter (range 4.2-12.1), 50% had pre-ART BMI >25 kg/m2, and three patients died (38%), accounting for 6.4% of deaths among patients taking stavudine. As long as HIV clinicians continue to use stavudine in sub-Saharan Africa, they should watch out for acute unexplained weight loss in patients taking ART, particularly among women and patients with high pre-ART BMI.

Risk behaviors in volunteer blood donors who seroconverted for HIV, Abidjan, Côte d'Ivoire 1997 to 2005

BACKGROUND

The residual risk of human immunodeficiency virus (HIV) transmission from blood products in the Abidjan National Blood Transfusion Center was estimated to be 1 in 5780 blood donations over the period 2002 through 2004. We aimed at describing risk behaviors in blood donors who seroconverted for HIV in Abidjan to improve the pre-blood donation selection.

STUDY DESIGN AND METHODS

We investigated the behavioral profile of HIV seroconverters assessed before their HIV diagnosis, during the blood donation selection at the blood bank of Abidjan, and compared it to the profile documented after this HIV diagnosis, at enrollment in the PRIMO-CI cohort. Since 1997, enrollment in this cohort is offered to every blood donor whose delay since HIV seroconversion was 36 months or less.

RESULTS

Among the 418 blood donors who seroconverted for HIV between 1997 and 2005, 241 were enrolled in the cohort. Median age was 28 years and 63% were men. The median time between the last HIV-negative test and the first positive test was 7 months. Since the last blood donation, 29% of donors reported unprotected sexual intercourse with multiple casual sexual partners, 55% unprotected sexual intercourse with one casual sexual partner, and 36% sharing of nail clippers. During the pre-blood donation questionnaire, 69% of HIV seroconverters had reported unprotected sexual intercourse since the last blood donation (vs. 89% reported after donation), and 7% had had multiple casual sexual partners (vs. 32%).

CONCLUSION

Volunteer blood donors who seroconverted for HIV in Abidjan reported a high proportion of unprotected sexual intercourse with casual sexual partners.

Progression to WHO criteria for antiretroviral therapy in a 7-year cohort of adult HIV-1 seroconverters in Abidjan, Côte d'Ivoire

OBJECTIVE

To estimate the probability of reaching the criteria for starting highly active antiretroviral therapy (HAART) in a prospective cohort of adult HIV-1 seroconverters in Abidjan, Côte d'Ivoire.

METHODS

We recruited participants from HIV-positive donors at the blood bank of Abidjan for whom the delay since the estimated date of seroconversion (midpoint between last negative and first positive HIV-1 test) was < 36 months. Participants were offered early trimethoprim-sulfamethoxazole (cotrimoxazole) prophylaxis, twice-yearly measurement of CD4 count and we made standardized records of morbidity. We used the Kaplan-Meier method to estimate the probability of reaching the criteria for starting HAART according to WHO 2006 guidelines.

FINDINGS

217 adults (77 women (35%)) were followed up during 668 person-years (PY). The most frequent diseases recorded were mild bacterial diseases (6.0 per 100 PY), malaria (3.6/100 PY), herpes zoster (3.4/100 PY), severe bacterial diseases (3.1/100 PY) and tuberculosis (2.1/100 PY). The probability of reaching the WHO 2006 criteria for HAART initiation was estimated at 0.09, 0.16, 0.24, 0.36 and 0.44 at 1, 2, 3, 4 and 5 years, respectively.

CONCLUSION

Our data underline the incidence of the early HIV morbidity in an Ivorian adult population and provide support for HIV testing to be made more readily available and for early follow-up of HIV-infected adults in West Africa.

Tolerance and Acceptability of an Efavirenz-Based Regimen in 740 Adults (Predominantly Women) in West Africa

In sub-Saharan Africa, the position of efavirenz as a first-line nonnucleoside reverse transcriptase inhibitor remains to be discussed. We report here the 6-month efficacy and tolerance of an efavirenz-containing highly active antiretroviral therapy in a large cohort of HIV-1-infected adults. Seven hundred forty highly active antiretroviral therapy-naive adults (74% women; 14% with positive serum HBs antigen and 21% with abnormal baseline transaminase value) started zidovudine + lamivudine + efavirenz. At month 6, 1.2% of them were dead, 87% had undetectable viral load, and 7% had abnormal transaminase value. From months 1 to 6, the percentage of women who were actually using a contraceptive method increased from 58% to 80% (65% intramuscular progesterone and 35% oral estrogen/progesterone combination). The incidence of pregnancy was 2.6/100 woman-years (95% confidence interval, 0.67-4.51), and 86% of pregnant women voluntarily interrupted the pregnancy with no intervention on our part. Before month 6, only 0.8% of patients permanently discontinued efavirenz for severe adverse effects (neurologic, 0.6%; cutaneous, 0.1%; and hepatic, 0.1%). The leading cause of severe morbidity was tuberculosis. Considering the very high hepatic and cutaneous tolerance, efavirenz could be considered as a valuable first-line drug for women of childbearing age who agree to use contraception in sub-Saharan Africa, provided that the risk of teratogenicity should be closely monitored.

[Profile of HIV infected patients among blood donors in Abidjan, Côte d'Ivoire (1992-1999)]

The FonSIDA is a private clinic created in 1992 within the premises of the National Blood Transfusion Center of Abidjan (CNTS), the largest city in Côte d'Ivoire. It provides medical and psychological follow-up for blood donors which are diagnosed as HIV-infected. This Centre provides blood for transfusions in Abidjan and the surrounding area, which from 1992 to 1999 collected 263,398 blood units. In this period, 5574 subjects were detected HIV-positive. Among those, 1766 (32%) HIV infected blood donors came back to be tested for confirmation of HIV diagnosis. Since then, only 9% of the 5574 donors have been seen at least twice a year for medical and psychological follow-up. Women were more compliant than men in the FonSIDA Clinic: they constituted 62% of the 409 patients who were followed-up (p < 0.001). 53% of men had sex with prostitutes the year before HIV diagnosis. 67% of women stated voluntary abortion at least once. In the same period the systematic use of condoms was reported by only 7% of women and 5% of men. 22% of women and 28% of men reported having two or more sexual partners in the year before HIV diagnosis. The main aim of every blood center is to improve blood safety, particularly in developing countries. The appropriate counseling towards blood donors and especially those detected HIV positive can contribute to reduce new HIV infections in high HIV prevalence cities. Rate of compliance of HIV-infected patients to follow-up has risen to 11% in 1992-1994 to 60% in 1997-1999 and will contribute to reach this aim.

Behavior Assessment of Blood Donors Facing the Risk of HIV Infection, Abidjan, Côte D'Ivoire, 2001-2002

Despite precautions taken to guarantee blood safety, in the National Blood Transfusion Center (CNTS) of Abidjan, about 30 regular blood donors are detected with HIV seroconversion each year, two-thirds of them men. A survey through face-to-face interviews was carried out at the CNTS of Abidjan from September 2001 to March 2002 among HIV-positive and HIV-negative regular blood donors, informed about their serologic status. HIV-negative regular blood donors informed about their serologic status since a median time of 67 months (n = 50) disclosed more risky behaviors such as multiple sexual partners (68%) than HIV-positive blood donors informed about their status (n = 112) since a median time of 35 months (41%) (P < 0.001). Condoms were systematically used by 17% of HIV-negative blood donors and 55% of HIV-positive blood donors (P < 0.001). Enhanced counseling and awareness could reduce in the future the number of cases of seroconversion among regular blood donors and improve their subsequent behavior. Blood donors who have unprotected sex with partners of unknown HIV serologic status and especially with casual partners are strongly exposed to HIV transmission and should be discouraged to continue giving blood, after adequate counseling.

[Bacillary angiomatosis in an adult infected with HIV-1 at an early stage of immunodepression in Abidjan, Côte d'Ivoire]

Human immunodeficiency virus (HIV)-associated bacillary angiomatosis has rarely been described in Africa. We report here the first case in Côte d'Ivoire. Although in industrialised countries bacillary angiomatosis has been described in patients with low CD4 count, this episode occurred in the first year following HIV-seroconversion in an adult patient with more than 500 CD4 cells per cubic millimetre. Symptoms rapidly and totally disappeared under erythromycin treatment, although with a relapse two years after the end of the first episode. In Africa where people living with HIV often present chronic cutaneous lesions, bacillary angiomatosis may be under-diagnosed. Bacillary angiomatosis must be systematically considered in face of lesions similar to Kaposi's sarcoma. Improving knowledge on symptoms of bacillary angiomatosis in Africa should lead to better treatment and a better estimation of its true frequency which may be underestimated.

Primary culture of porcine mammary epithelial cells as a model system for evaluation of milk protein expression

Porcine mammary epithelial cells were isolated to culture on collagen gel followed by gel floating treatment to evaluate differentiation under the culture conditions of serum-free medium, supplemented with combinations of insulin, hydrocortisone, and prolactin. After the culture period, the mammary cells attached to the collagen gels were recovered to observe expression of beta-casein, beta-lactoglobulin, and lactoferrin by reverse transcriptase polymeric chain reaction method. Expression of beta-casein was observed in the presence of insulin, hydrocortisone, and prolactin whereas transcription of beta-lactoglobulin and lactoferrin occured irrespective of hydrocortisone and prolactin. Immunoblot analysis demonstrated synthesis and secretion of lactoferrin in the fraction of recovered cells and the culture medium.

Severe complications of ulcerative colitis after high-dose prednisolone and azathioprine treatment

We report a rare case of ulcerative colitis (UC) associated with methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa infections in multiple organs, and with compressive fracture from osteoporosis after the administration of high-dose prednisolone and azathioprine. A 25-year-old man had been treated with high-dose prednisolone for UC. He suddenly experienced severe lumbago, which prevented him from walking. Plain X-ray demonstrated compressive fractures of the thoracic and the lumbar vertebrae, which were thought to be due to osteoporosis as a side effect of the high-dose prednisolone. At this admission, in another hospital, he also had a bloody discharge from the rectum, and azathioprine was started; however, the patient's condition still did not show any improvement. The total doses of azathioprine and prednisolone he had received were 3150 mg and more than 15,000 mg, respectively. Considering the presence of the serious complications, surgical intervention was the treatment selected. Culture study revealed MRSA in the feces and nasal cavity, and P. aeruginosa in the feces and urine. Vancomycin hydrochloride and gentamicin were administered, and were effective, with a subsequent negative culture study. Subtotal colectomy with mucus fistula was performed. After the operation, culture studies remained negative. Major steroid side effects such as bone fracture and osteoporosis should be considered as an indication for surgery in UC patients. MRSA and P. aeruginosa are a menace, especially for UC immunosuppressed patients on steroid or immunosuppressive therapy. When these bacteria are detected, there should be prompt and adequate antimicrobial therapy against the organisms and the immunosuppressive therapy should be immediately discontinued. We conclude that surgical therapy should be considered in the earlier stage for patients with intractable UC, rather than continuing long-term administration of steroid or azathioprine, which may lead to serious complications.

Rapid growth of residual colonic tumor after incomplete mucosal resection

We report an 89-year-old man with colon cancer that developed rapidly after an incomplete endoscopic mucosal resection (EMR), and discuss the adverse effect of this maneuver on the tumor biology. A sessile polyp, 15 mm in size, was detected at the hepatic flexure. EMR was performed immediately. Histological examination showed well differentiated adenocarcinoma with an adenomatous component invading the submucosal layer. There was vascular invasion (positive on elastica van Gieson staining) and the surgical margin was positive for cancer. A right hemicolectomy was performed. The surgical specimen showed the residual tumor, 22 mm in diameter. The relevant histopathological findings of the surgical specimen were: well differentiated adenocarcinoma, with partly mucinous carcinoma and a tubular adenomatous component, depth muscularis propria (mp), lymph node (LN) (0/9). Most of the submucosally invasive cancer was resected by the initial EMR, but the small residual tumor showed rapid growth within only 3 months after the EMR. It was assumed that the residual tumor cells had acquired more malignant characteristics after EMR. In regard to EMR we propose that: (1) except for patients who are at high risk for a major operation, EMR should be avoided for carcinoma with massive submucosal invasion, (2) colonic resection should be performed immediately when histology shows a positive surgical margin for carcinoma, and (3) patients operated after an incomplete EMR should be watched very carefully for the detection of recurrence.

Endoscopic resection for submucosally invasive colorectal cancer: is it feasible?

BACKGROUND

Recent advances in colonoscopy have resulted in an increasing number of endoscopic resections of colorectal neoplasms. However, endoscopic resection of submucosal invasive cancer remains a controversial issue.

METHODS

The subjects for this study were the surgically treated patients with submucosal invasive colorectal cancer. These patients were classified into two groups: those with versus those without preoperative endoscopic resection. Clinicopathologic features and prognosis were compared and analyzed.

RESULTS

Fifty patients underwent surgery for submucosally invasive colorectal cancer. Numbers of patients with and without preoperative endoscopic resection were 22 and 28, respectively. In 36.4% of the patients, endoscopic resections were incomplete. Two patients in whom the preoperative endoscopic resections had revealed a positive cancer margin, had nodal metastasis. One of these patients also developed hepatic metastasis. Endoscopic findings such as diameter and shape were not indicative of either lymphatic or vascular invasion. There were no morbidities or mortalities associated with endoscopic resection or surgery.

CONCLUSIONS

Preoperative endoscopic resection for colorectal submucosal cancer is feasible, provided the resection is complete. The indications for surgical treatment should be determined after pathologic examination.

Appendico-ileo-vesical fistula

Appendico-vesical fistula is a rare condition. In total, 109 cases, most secondary to appendicitis, have been reported in the English-language literature. We report the first case, to our knowledge, of appendico-ileo-vesical fistula secondary to appendiceal diverticulitis. An enterovesical fistula was diagnosed by urine culture, cystoscopy, and computed tomography. The locations of enteric opening sites were demonstrated by barium enema and colonoscopy. Ileocecal resection and fistulectomy with primary reconstruction were performed. We believe that accurate pre- and intra-operative diagnosis is essential for cure. This case demonstrates the importance of barium enema and colonoscopic examinations in the diagnosis and treatment of complicated enterovesical fistula.

Clear demonstration of carcinoma of the ampulla of Vater with ultrasonography

We present a non-icteric case, in which an ampullary polypoid lesion was clearly demonstrated by ultrasonography, suggesting carcinoma of the ampulla of Vater. The lesion was a 3 cm in diameter, spherical tumor with a polypoid surface, and internal hyperechogenicity. The patient underwent a curative pylorus-preserving pancreaticoduodenectomy.

Vectorcardiographic evaluation of myocardial infarct size: departure parameters are superior to conventional spatial parameters

To determine whether the departure parameters derived from a "departure loop" of a vectorcardiogram are more accurate than conventional spatial parameters in evaluating myocardial infarct size, 74 patients with first-onset myocardial infarction (MI) were studied. The correlation between the departure parameters (amplitudes in scalar leads of the departure loop) and the percent defect volume of thallium myocardial scintigrams (%DV) was compared with that of the spatial parameters (magnitude, azimuth, and elevation of the original QRS loop). In anteroseptal MI, the amplitude of a 20-msec vector in the z-axis and the azimuth of a 30-msec vector (H30) were significantly correlated with %DV (r=0.783, p<0.001 and r=0.572, p<0.05). In anteroseptal MI with involvement of the lateral wall, the amplitude of a 30-msec vector in the x-axis and H30 showed significant correlation with %DV (r=0.802, p<0.001 and r=0.772, p<0.01). In inferior and inferoposterior MI, the amplitude of a 30-msec vector in the y-axis and the elevation of a 30-msec vector were significantly correlated with %DV (r=0.920, 0.891, p<0.001 and r=0.871, 0.678, p<0.01, respectively). In conclusion, the departure parameters are more accurate than the spatial parameters for evaluation of myocardial infarct size.

Reactive lymphoid hyperplasia of the liver characterized by an angiofollicular pattern mimicking Castleman's disease

A case of reactive lymphoid hyperplasia of the liver exhibiting a characteristic angiofollicular pattern is reported. A hepatic nodular lesion was discovered by abdominal echography during clinical follow-up of abnormal liver function tests. It was diagnosed as hepatocellular carcinoma because of its hypervascularity when observed by angiography, and surgically resected. Grossly, the lesion was well-demarcated and measured 2 cm in diameter. Microscopically, the nodule was composed of lymph follicles with germinal centers, and the hyalinized inter-follicular space contained abundant hyalinized vasculature and plasma cells. The surrounding liver tissue exhibited chronic inflammation with some peculiar angiofollicular structures mimicking Castleman's disease. An immunohistochemical study revealed that the angiofollicular structure had the same characteristics as a lymph follicle with a germinal center, and that the plasma cells proliferating in the inter-follicular space had polyclonal immunophenotypes. These histological and immunohistochemical findings indicated that the angiofollicular structure observed was a kind of reactive lymph follicle, and that this hepatic lesion was reactive lymphoid hyperplasia rather than Castleman's disease or an inflammatory pseudotumor.

P wave changes in body surface potential maps due to increasing heart rate during exercise in normals

Exercise-induced changes in P maps were investigated in normal subjects (n = 20) in order to clarify the basic changes in P maps caused by exercise in patients with ischemic heart disease or by exercise-induced dysfunction of the left ventricle in patients with various heart diseases. Maps were obtained using an 87 lead-point system (HPM-6500, Chunichi-Denshi Corporation) and were recorded at rest and at heart rates up to 140/min in 20/min steps under graded bicycle ergometric exercise. P waves were divided into 3 phases (initial, middle and terminal) by locating the maximum. Maps were characterized by the distribution pattern of the positive and negative potentials in each frame. Peak voltages increased proportionally to the increase in heart rate. We observed a decrease in P wave duration concomitant with the increase in heart rate. Time from P onset to peak voltage increased slightly. We believe these findings to be due to the acceleration of sympathetic nerve tone accompanying exercise. We observed 2 patterns: type A showed the relatively short middle and terminal phases, and type B a prolongation of the middle phase and a shortening of the terminal phase. We consider the differences between types A and B to be partly due to individual differences in the degree of increase in pulmonary air volume and sympathetic nerve tone influence on the atria. In evaluating the exercise-induced P map changes, special consideration should be paid to the changes due to increase in heart rate.

Serum beta-enolase in acute myocardial infarction

The enzyme beta-enolase (alpha beta and beta beta forms) is present in skeletal and heart muscle and catalyses the glycolysis of 2-phosphoglycerate to phosphoenolpyruvate. The enzyme was measured in serum samples from patients with acute myocardial infarction, angina pectoris, congestive heart failure, and idiopathic cardiomyopathy. Serum concentrations of beta-enolase were significantly increased in acute myocardial infarction but not in the other cardiovascular diseases. Activity peaked approximately 12 to 14 hours after an acute attack of chest pain, and then gradually decreased as the patient recovered. The rise and fall in beta-enolase concentration were faster and steeper than those of creatine kinase activity, particularly in patients in whom activities of both these enzymes were less high. The assay of beta-enolase, which is highly specific and sensitive, has considerable advantages for the early diagnosis of myocardial infarction and the diagnosis of a second episode of myocardial infarction because beta-enolase concentration increases very early and rapidly and clears quickly. These data imply that serum beta-enolase may be a more effective marker for early myocardial infarction, particularly in milder cases, than measurement of creatine kinase activity.

Asthma: the yoga perspective. Part II: Yoga therapy in the treatment of asthma

The integral yoga approach to asthma (and other psychosomatic disorders) is briefly outlined as meeting all of the requirements for an optimal, holistic, somatopsychic therapy (as outlined in Part I), including correction of distorted posture and faulty breathing habits, teaching a system of general muscle relaxation, techniques for the release of suppressed emotion and for reducing anxiety and self-conscious awareness, as well as special methods for the expectoration of mucus. Yoga practices are described in detail and the available psychophysiological research on yoga practice, as well as clinical-therapeutic studies on yoga as asthmatic therapy, are reviewed. It can therefore be concluded that yoga therapy is most effective with asthma.