Elisabeth Aslangul

Rosuvastatin versus pravastatin in dyslipidemic HIV-1-infected patients receiving protease inhibitors: a randomized trial.

Background:HIV infection and its treatment with protease inhibitors, especially when boosted with ritonavir, can cause lipid disorders. Statins, with the exception of fluvastatin, pravastatin and rosuvastatin, interact with protease inhibitor metabolism via CYP450. Pravastatin is recommended for patients with protease inhibitor-associated dyslipidemia. Rosuvastatin is the statin most effective on low-density lipoprotein cholesterol (LDL-c) in non-HIV patients. Methods:HIV-1-infected patients treated with boosted protease inhibitor were randomized to receive either rosuvastatin 10 mg/day or pravastatin 40 mg/day for dyslipidemia (LDL-c >4.1 mmol/l and triglycerides <8.8 mmol/l). The percentage change in LDL-c, triglyceride and high-density lipoprotein-cholesterol levels, measured in a central laboratory, was determined after 45 days of statin treatment. Results:Eighty-eight patients were randomized and 83 took the study drugs, 41 rosuvastatin and 42 pravastatin. The median duration of prior antiretroviral treatment was 9 years. At baseline, the median LDL-c level was 4.93 mmol/l, the triglyceride level 2.29 mmol/l, and the high-density lipoprotein-cholesterol level 1.27 mmol/l. The median percentage changes in the rosuvastatin and pravastatin arms were −37 and −19% for LDL-c (P < 0.001), respectively, and −19 and −7% for triglycerides (P = 0.035), respectively. The change in the high-density lipoprotein-cholesterol level was not significantly different between the two arms. None of the four severe adverse events was attributed to the statins; in particular, there were no renal, hepatic or muscular events. Conclusion:Rosuvastatin 10 mg/day was more effective than pravastatin 40 mg/day on LDL-c and triglyceride levels in HIV-1-infected patients receiving a boosted protease inhibitor.

Bone pain due to fractures revealing osteomalacia related to tenofovir-induced proximal renal tubular dysfunction in a human immunodeficiency virus-infected patient.

Tenofovir is a nucleoside reverse transcription inhibitor used to treat human immunodeficiency virus patients with early treatment failure. Increasing numbers of cases of tubular dysfunction and Fanconi syndrome have been reported in patients treated with tenofovir, after the detection of biochemical abnormalities during routine assessments. Some patients have acute renal failure, and bone involvement is observed in rare cases. We describe a case of chronic metabolic complications with bone fractures related to tenofovir treatment. Several factors that increased the renal toxicity of tenofovir included low body mass index, concomitant use of nonsteroidal anti-inflammatory agents, and other antiretroviral drugs, including ritonavir.

High-sensitivity C-reactive protein levels fall during statin therapy in HIV-infected patients receiving ritonavir-boosted protease inhibitors.

HIV-infected patients are at an increased risk of developing cardiovascular disease. Elevated levels of C-reactive protein (CRP) are associated with an increased risk of cardiovascular disease in the general population and are reduced by statin therapy. We examined the effect of pravastatin and rosuvastatin on CRP levels in 58 dyslipidemic HIV-infected patients. A 45-day course of either statin reduced the median CRP level from 3.0 to 2.4 mg/l (P < 0.001) with no correlation with changes in lipid parameters.

Diagnosing Diabetic Foot Osteomyelitis in Patients Without Signs of Soft Tissue Infection by Coupling Hybrid 67Ga SPECT/CT With Bedside Percutaneous Bone Puncture

OBJECTIVE Successful treatment of osteomyelitis is more likely with accurate diagnosis and identification of the causative pathogens. This typically requires obtaining a specimen of bone, usually by image-guided biopsy. We sought to develop a simpler bedside method for definitively diagnosing osteomyelitis. RESEARCH DESIGN AND METHODS Over 2 years, we enrolled consecutive patients presenting to our diabetic foot clinic with a foot ulcer and clinically suspected osteomyelitis but without soft tissue infection. Each underwent hybrid 67Ga single-photon emission computed tomography and X-ray computed tomography (SPECT/CT) imaging; those with a positive scan underwent bedside percutaneous bone puncture. Patients with a positive bone culture received culture-guided antibiotic therapy. Patients with negative 67Ga SPECT/CT imaging or with positive imaging but negative bone culture were not treated with antibiotics. All patients were followed up for ≥1 year. RESULTS Among 55 patients who underwent 67Ga SPECT/CT imaging, 13 had negative results and all of their foot ulcers resolved without antibiotic therapy. Among 42 with positive imaging, 2 were excluded (for recent antibiotic therapy) and 40 had bone punctures (3 punctured twice): 19 had negative results, 3 of which were likely false negatives, and 24 had positive results (all gram-positive cocci). At follow-up, 3 patients had died, 3 had undergone amputation, and 47 had no evidence of foot infection. The sensitivity and specificity of this combined method were 88.0 and 93.6%, respectively, and the positive and negative predictive values were 91.7 and 90.7%, respectively. CONCLUSIONS Coupling of 67Ga SPECT/CT imaging and bedside percutaneous bone puncture appears to be accurate and safe for diagnosing diabetic foot osteomyelitis in patients without signs of soft tissue infection, obviating the need for antibiotic treatment in 55% of suspected cases.

Twelve Months of Routine HIV Screening in 6 Emergency Departments in the Paris Area: Results from the ANRS URDEP Study

Objective In October 2009 the French National Authority for Health recommended that HIV testing be proposed at least once to all persons aged 15 to 70 years in all healthcare settings. We examined whether routine HIV screening with a rapid test in emergency departments (EDs) was feasible without dedicated staff, and whether newly diagnosed persons could be linked to care. Methods This one-year study started in December 2009 in 6 EDs in the Paris area, using the INSTI™ test. Eligible individuals were persons 18 to 70 years old who did not present for a vital emergency, for blood or sexual HIV exposure, or for HIV screening. Written informed consent was required. Results Among 183 957 eligible persons, 11 401 were offered HIV testing (6.2%), of whom 7936 accepted (69.6%) and 7215 (90.9%) were tested (overall screening rate 3.9%); 1857 non eligible persons were also tested. Fifty-five new diagnoses of HIV infection were confirmed by Western blot (0.61% (95% CI 0.46–0.79). There was one false-positive rapid test result. Among the newly diagnosed persons, 48 (87%) were linked to care, of whom 36 were not lost to follow-up at month 6 (75%); median CD4 cell count was 241/mm3 (IQR: 52–423/mm3). Conclusions Screening rates were similar to those reported in opt-in studies with no dedicated staff. The rate of new diagnoses was similar to that observed in free anonymous test centres in the Paris area, and well above the prevalence (0.1%) at which testing has been shown to be cost-effective.

Human Bartonella Infective Endocarditis is Associated with High Frequency of Antiproteinase 3 Antibodies

To the Editor: nnBartonella henselae and B. quintana are the 2 Bartonella species most commonly involved in human disease and are associated with the formation of vasoproliferative tumors1. Chronic infections are bacteremia (particularly affecting homeless patients), endocarditis, bacillary angiomatosis, and liver peliosis2. Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides are a group of diseases characterized by necrotizing vasculitis of small vessels and associated with autoantibodies against neutrophil constituents such as myeloperoxidase (MPO) and proteinase 3 (PR3)3. Granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MP), and Churg-Strauss syndrome (CSS) are all forms of vasculitis associated with anti-PR3. Several chronic infectious diseases (mycobacterial infections, chronic hepatitis C virus infection, and amoebic liver abscess) have been reported to be associated with a positive ANCA by immunofluorescence, but the specificity was not always defined by ELISA-testing specificity4. A few cases of subacute endocarditis have been reported to be associated with ANCA positivity, mainly anti-PR3.nnA 40-year-old … nnAddress correspondence to Dr. E. Aslangul, Internal Medicine Department, Hotel Dieu 1, Place du Parvis Notre Dame, 75004 Paris, France. E-mail: elisabeth.aslangul{at}htd.aphp.fr

L’enseignement de la médecine narrative peut-il être une réponse à l’attente de formation des étudiants à la relation médecin–malade ?

INTRODUCTIONnComing from literature and medicine and medical humanities north American seminars, narrative medicine has applied narratology for analyzing patients discourse and has been taught during a decade.nnnMETHODSnAt Paris Descartes School of Medicine a twenty-hour narrative medicine elective program including whole class lectures and writing and reading small group exercises for second year medical students has been assessed using satisfaction questionnaires.nnnRESULTSnAlthough several students were uncomfortable with the first writing and reading exercises, the whole satisfaction scores demonstrate that this new program is very well appreciated even when students did not choose this program because they were interested with the patient physician relationship. These results have been confirmed when all students state this program should be continued and when half of them state this program should be offered to more students or made mandatory.nnnDISCUSSIONnThe primary focus on literary characteristics of patients and physicians discourses, without ignoring psychoanalysis theory, has shown to be safe for young students. Writing exercises are encouraged but not mandatory, and reading is optional if ever they feel embarrassed after producing their own texts. Narrative medicine impact on students attitudes and behaviors has now to be assessed before implementing new educational programs.

Is Impact of Statin Therapy on All-Cause Mortality Different in HIV-Infected Individuals Compared to General Population? Results from the FHDH-ANRS CO4 Cohort.

Background The effect of statins on all-cause mortality in the general population has been estimated as 0.86 (95%CI 0.79-0.94) for primary prevention. Reported values in HIV-infected individuals have been discordant. We assessed the impact of statin-based primary prevention on all-cause mortality among HIV-infected individuals. Methods Patients were selected among controls from a multicentre nested case-control study on the risk of myocardial infarction. Patients with prior cardiovascular or cerebrovascular disorders were not eligible. Potential confounders, including variables that were associated either with statin use and/or death occurrence and statin use were evaluated within the last 3 months prior to inclusion in the case-control study. Using an intention to continue approach, multiple imputation of missing data, Cox’s proportional hazard models or propensity based weighting, the impact of statins on the 7-year all-cause mortality was evaluated. Results Among 1,776 HIV-infected individuals, 138 (8%) were statins users. During a median follow-up of 53 months, 76 deaths occurred, including 6 in statin users. Statin users had more cardiovascular risk factors and a lower CD4 T cell nadir than statin non-users. In univariable analysis, the death rate was higher in statins users (11% vs 7%, HR 1.22, 95%CI 0.53-2.82). The confounders accounted for were age, HIV transmission group, current CD4 T cell count, haemoglobin level, body mass index, smoking status, anti-HCV antibodies positivity, HBs antigen positivity, diabetes and hypertension. In the Cox multivariable model the estimated hazard ratio of statin on all-cause mortality was estimated as 0.86 (95%CI 0.34-2.19) and it was 0.83 (95%CI 0.51-1.35) using inverse probability treatment weights. Conclusion The impact of statin for primary prevention appears similar in HIV-infected individuals and in the general population.

Effects of rosuvastatin versus pravastatin on low-density lipoprotein diameter in HIV-1-infected patients receiving ritonavir-boosted protease inhibitor.

Objective:HIV infection is associated with an atherogenic lipoprotein profile, and ritonavir-boosted protease inhibitors exacerbate this phenotype. We evaluated the effect of 45 days of rosuvastatin versus pravastatin on the low-density lipoprotein (LDL) size and the distribution of LDL subfractions in HIV-1 patients receiving boosted protease inhibitors with elevated LDL levels. Design:Substudy of the randomized double-blind multicentre ANRS 126 VIHstatine trial. Setting:Twenty clinical centres in France. Patients:HIV-infected patients receiving boosted protease inhibitors with dyslipidaemia (LDL cholesterolu200a>u200a4.1u200ammol/l and triglyceridesu200a<u200a8.8u200ammol/l). Intervention:Rosuvastatin 10u200amg/day (nu200a=u200a39) or pravastatin 40u200amg/day (nu200a=u200a37) for 45 days. Main outcome measure(s):LDL size and distribution of LDL subfractions blindly assessed by gradient gel electrophoresis at baseline and at day 45. Results:Rosuvastatin was more effective than pravastatin in increasing the diameter of the LDL peak. The LDL diameter change was 0.33u200a±u200a0.59u200anm in the rosuvastatin group versus −0.01u200a±u200a0.52u200anm in the pravastatin group (Pu200a=u200a0.021). Rosuvastatin was also more effective in increasing significantly the percentage of large LDL (LDL1, Pu200a=u200a0.038; LDL2, Pu200a=u200a0.031) and in decreasing the percentage of small LDL (LDL3, Pu200a=u200a0.009). Conclusion:Rosuvastatin was more effective than pravastatin in normalizing LDL size and LDL subfraction distributions, leading to a less atherogenic phenotype.

Abcès cutanés aseptiques récidivants atypiques révélateurs d’une maladie de Crohn

INTRODUCTIONnWe report here a case of chronic inflammatory bowel disease revealed by multiple large cutaneous aseptic distal necrotic ulcers.nnnCASE REPORTnA 44-year-old male presented with high fever at 40°C associated with multiple necrotic abcesses located on the distal part of his limbs. They were treated successfully by debridment and dressings associated with antibiotics allowing complete healing after 1xa0month. Six months later, the patient relapsed on his left hand with a short episode of diarrhoea. A total coloscopy revealed a Crohns disease. Systemic corticotherapy and azathioprine were administered and complete remission was obtained with a 1-year follow-up.nnnCONCLUSIONnSkin manifestations that this patient presented were atypical because of their number, size, and location, exclusively distally on the limbs. This report illustrates an unusual presentation of Crohns disease with multiple necrotic ulcers only located on the patient extremities.