Pediatricians should offer routine HIV testing to adolescent and young adult patients, American Academy of Pediatrics recommends in academy’s new policy statement published November print issue of Pediatrics.

It says

In light of the increasing numbers of people with HIV/AIDS and missed opportunities for HIV testing, the Centers for Disease Control and Prevention…recommends universal and routine HIV screening rather than targeted testing.

Specific  Recommendations

• When HIV prevalence in the patient population exceeds 0.1%, all adolescents should be offered routine HIV screening at least once by 16 to 18 years of age.
• In areas where HIV prevalence in the community is lower, all sexually active adolescents and those with substance use or other risk factors for HIV should have routine HIV testing.
• Annual HIV testing is recommended for high-risk youth, and adolescents undergoing testing for other sexually transmitted infections (STIs) should be tested for HIV at the same visit.
• Routine HIV testing should be implemented in emergency departments and urgent care facilities in high-prevalence areas.
• Physicians should be aware of the symptoms of acute retroviral syndrome and consider HIV RNA testing for viral load in youth with appropriate risk factors.
• Adolescent consent should suffice for testing and treatment for HIV infection or STIs, although parental involvement is always desirable. If there are cost or confidentiality issues, free and confidential community-based testing programs are available.
• Regardless of perceived risk, pediatricians should routinely ask adolescents about sexual and substance use behaviors, ideally using standardized assessment tools and a confidentiality protocol.
• Pediatricians should foster an environment of tolerance to facilitate frank, nonjudgmental discussion of gender and sexual orientation.
• If permitted by state laws, opt-out HIV testing is preferred. Rapid HIV testing offers immediate preliminary results and is similarly sensitive to enzyme immunoassays. If routine HIV opt-out testing in adolescents is not permitted by state laws, physicians are encouraged to advocate for change.
• To reduce future risk, adolescents with a negative HIV test result should be counseled regarding sexual and drug use behaviors.
• Adolescents with a positive HIV test result should be referred to age-appropriate HIV specialty care, including prenatal care if needed.
• Pediatricians are encouraged to advocate for prevention education and access to confidential HIV and STI testing for adolescents, in addition to counseling and HIV treatment.
• Preventive care screening should include universal coverage and sufficient reimbursement for HIV testing and related counseling. Physicians should advocate for confidential billing practices for HIV and STI testing in adolescents and young adults.

Pediatrics. 2011;128:1023-1029.

Treatment with gantenerumab, an anti–amyloid-β monoclonal antibody, results in a dose-dependent reduction in brain amyloid in patients with mild to moderate Alzheimer’s disease, a small trial shows.

However the study found no  effects on cognitive measures and doubts whether any reduction in brain amyloid level will translate into clinical efficacy.

Findings  were reported online October 10 in the Archives of Neurology.

The authors commented that administering gantenerumab circumvents stimulation of the adaptive immune system and ensures adequate antibody exposure in the Alzheimer’s patient.

The study included data from 16 patients of Alzheimer’s disease aged between 50 to 90 years, who were included in a positron emission tomographic (PET) substudy of a larger multiple ascending dose trial.

Inclusion criteria was

• Probable Alzheimer’s disease according to the National Institute of Neurological Disorders and Stroke Alzheimer’s Disease and Related Disorders Association criteria
• Mini-Mental State Examination Score between 16 and 26
• Mmagnetic resonance imaging scan consistent with Alzheimer’s disease
• Modified Hachinski ischemia score of 4 or less.

The patients were assigned to receive intravenous infusions of gantenerumab (60 mg in 6 patients and 200 mg in another  6.  Placebo was given in 4 patients. The infusion was given once every four weeks. All patients were sheduled to receive a total of 7 infusions.

But because of early termination of dosing in the 200-mg gantenerumab group, not all participants received 7 infusions.

In the 60-mg group, all patients received 7 infusions, while in the 200-mg group 1 patient received 5 infusions, 2 patients received 4 infusions, 2 patients received 3 infusions, and 1 patient received 2 infusions.

In the placebo group, 2 patients received all 7 infusions, 1 patient received 5 infusions, and 1 patient received 2 infusions.

Carbon 11-labeled Pittsburgh compound B positron emission tomography was used to measure the changes in amyloid brain by comparing baseline images with images obtained at the end of treatment

The study found a mean percentage reduction from baseline in cortical brain amyloid relative to placebo of 15.6% in the 60-mg group and 35.7% in the 200-mg group.

Two patients treated with gantenerumab, , showed abnormalities on MRI fluid-attenuated inversion recovery imaging [FLAIR imaging. Both patients also developed microhemorrhages, and 1 was mildly symptomatic. The adverse effects resolved spontaneously after discontinuation of dosing

A smaller reduction in amyloid was seen with no FLAIR abnormalities at a lower dose of gantenerumab.

Authors said that this suggested that gantenerumab-induced amyloid lowering can be achieved without significantly perturbing vascular permeability when appropriate dosing is selected.

The authors also mentioned that a phase 2 clinical trial is underway to investigate whether a clinical benefit can be achieved with gantenerumab-treated patients.

The study was funded by F. Hoffmann-La Roche Ltd.

Arch Neurol. Published online October 10, 2011.

Prematurely born babies have a very high risk for epilepsy, not only at age 5 or 6, but as young adults in their 20s and 30s. the fact has been pointed by a recent cohort  study from Sweden led by Casey Crump, MD.

The study found that people who were born very preterm [23 to 31 weeks of gestation] had a 5-fold increased risk for epilepsy at the ages of 25 to 37 years when compared those  who were born full-term.

The study has been published in the October issue of Neurology.

The researchers conducted a national cohort study of 630,090 individuals who were born in Sweden between 1973 and 1979. Of these, 27,953 people were born preterm [< 37 weeks of pregnancy].

The cohort was followed for 4 years, from 2005 to 2009, for hospitalization as well outpatient  prescription of antiepileptic drugs throughout Sweden.

The study calls for greater awareness among physicians, as well as survivors of preterm birth and their families about the long-term health effects.

Neurology. 2011;17:1376-1382.

Frequent use of aspirin is associated with early and late aging macula disorder (AMD). The risks for those problems appear to be linked to how often aspirin is consumed.

A study of nearly 4691 European patients aged 65 years or older  published online September 13 in Ophthalmology has published these findings.

Dr. de Jong and colleagues conducted a cross-sectional, population-based study using structured interviews to assess aspirin use and AMD in 4691 people living in 7 European countries – Norway, Estonia, United Kingdom, France, Italy, Greece, and Spain.

Following parameters were enquired

• Aspirin use [Gauged using a precoded response category of 7 options ranging from never to daily
• Sociodemographic status
• Education level
• Smoking history
• Alcohol consumption
• Medical history – Stroke, myocardial infarction, angina or diabetes mellitus.

Cholesterol levels were also determined using fasting blood samples.

Digitized fundus images were evaluated by 2 experienced staffers and graded according to the International Classification and Grading System for Age-Related Maculopathy and AMD.

About 41% of participants reported monthly aspirin use, 7% reported using aspirin at least once weekly, and 17.3% reported daily use..

36.4% of the participants had evidence of early AMD and 3.3% had evidence of late AMD.

For daily aspirin users had a steady increase with increasing severity of AMD.

Limitation of Study

The study was a cross-sectional study, and the possibility that people with AMD took aspirin after experiencing visual problems cannot be excluded.

The authors concluded that the observation warrants further evaluation of the associations between aspirin use and AMD.

Ophthalmology. Published online September 13, 2011. Abstract

There are are two sources of fluid in our body

• Exogenous – What we ingest

• Endogenous Water released from oxidation of ingested food

Water is lost from the body by following routes

•  Lungs – About 400 ml of water is lost in expired air each 24 hours [More in . In a dry atmosphere and with higher respiration rate]
• Skin – By perspiration is always occurring. Varies with the atmospheric temperature and humidity, muscular activity and body temperature. Average loss is between 600 and 1000 m per 24 hours.
• Faeces. Between 60 and 150 ml per day, increases in diarrohea.
• Urine – In a healthy adult,the normal urinary output is approximately 1500 mlin 24 hours [Minimum required to o excrete the end products of protein metabolism - 400 ml in 24 hours]

Water depletion

Pure water depletion is usually either due to diminished intake for any reason [Lack of availability, difficulty or inability to swallow because of painful conditions of the mouth and pharynx, or obstruction in the oesophagus] or  increased loss from the lungs after tracheostomy.

The main symptoms are weakness and intense thirst. The urinary output is diminished and its specific gravity increas­ed. There is a shift of intracellular fluid to extracellular in an attempt to compensate.

Water intoxication

This occurs when excessive amounts of water, low sodium or hypotonic solutions are taken or given by any route.

• The commonest cause Overprescription of intravenous fluids
• Colorectal washouts with plain water
• Ttransurethral resection of the prostate can cause this by excessive uptake of water (and glycine) from irrigation fluid.

Water intoxication can occur if the body retains water in excess to plasma solutes as in Syndrome of inappropriate antidiuretic hormone (SIADH) secretion.

Clinical features of water intoxication are

• Drowsiness
• Weakness
• Dilute urine except in SIADH
• Fallen hematocrit and electrolytes
• Nausea 7 vomiting of clear fluid
• Convulsions and coma.

Treatment is by water restriction. If the patient fails to improve, transfer to an intensive care or high dependency unit will be necessary for more invasive monitoring and controlled manipulation of fluids and electrolytes.

Varicose veins are veins that have become enlarged and tortuous.

The term commonly refers to the veins on the leg.

Varicose Veins In Left Leg

Varicose Veins in the above photograph were seen in a 56 years old male who visited the OPD for some other ailment.

Recurrent bleeding episodes in a joint can lead to chronic changes in the joint occur. These changes affect all of the tissues within and surrounding the joint: synovium and cartilage, capsule and ligaments, bone and muscles.

Chronic synovitis is usually seen in the first and second decades of life and the management of chronic hemophilic arthropathy depends on the stage at which it is seen.

Following stages are seen in hemarthroses in hemophilia.

Chronic synovitis

With repeated episodes of  bleeding in a joint, there occurs chronic inflammation of the  and hypertrophy of the synovium occurs. This causes swelling of the joint and on palpation a doughy soft tissue swelling is palpated. The  swelling is usually not tense and often accompanied by muscle atrophy. However, usually, a good range of motion is preserved.

Ultrasound and magnetic resonance imaging  usually confirms the diagnosis. The presence of synovial hypertrophy may be confirmed by ultrasonography and MRI.

At synovitis stage, the goal of treatment is to control the synovitis and maintain good joint function.

Measures include:

• Daily strength exercises
• Prevent further bleeding to factor levels should be maintained with a frequency that is needed  for a particular patient.
• In case the concentrate is not available in sufficient doses, short treatment courses (6-8 weeks) of secondary prophylaxis with intensive physiotherapy is beneficial.
• Non steroidal anti inflammatory drugs
• Intra-articular injection of a long-acting steroid.
• Synovectomy should be considered if a chronic synovitis persists with frequent recurrent bleeding not controlled by other means. It could be either by surgery or chemical synovectomy using radioisotope or rifampicin or oxytetracycline.

Chronic hemophilic arthropathy

It is caused by a persistent chronic synovitis and recurrent hemarthroses resulting in irreversible damage to the joint cartilage. Advancing cartilage loss results in  a progressive arthritis condition develops along with secondary soft tissue contractures, muscle atrophy, and angular deformities.

As the condition advances the swelling decresesre is less swelling due to progressive fibrosis of the synovium and the capsule. There is considerable loss of motion. Radiographic features of this stage are  soft tissue swelling, epiphyseal overgrowth, osteoporosis, joint space narrowing, bony erosions and subchondral bone cysts. Ankylosis may result eventually.

The treatment at this stage aims at pain relief and improvement of joint function and includes following option

• Supervised physiotherapy
• Non steroidal antiinflammatory drugs
• Casting/orthoses
• Surgical measures if conservative therapy fails. Surgical options are
  • Radionucleotide synoviorthesis
  • Extra-articular soft tissue release
  • Arthroscop adhesions release
  • Elbow synovectomy with radial head excision
  • Corrective osteotomy
  • Prosthetic joint replacement
  • Arthrodesis

Following is the clinical photograph of the patient showing marked redness in the leg .

Marked Redness Of Left Leg Because of Cellulitis

The redness is an important sign of inflammation The patient had cellulitis and did not have any comorbidity.

The patient was treated with antibiotics and elevation of the limb.

A recent article published in Chest has reported that use of Non steroidal antiinflammatory drugs may cause an alteration inn presentation and course of pneumonia.

The article is published in journal Chest in February issue and the authors in order are Guillaume Voiriot, Sandra Dury, Antoine Parrot, Charles Mayaud and Muriel Fartoukh

Nonsteroidal antiinflammatory drugs are used very commonly for pain and fever. The authors wanted to investigate the potential influence of Nonsteroidal antiinflammatory drugs (NSAIDs) on the presentation and short-term outcomes of nonimmunocompromised inpatients with community-acquired pneumonia admitted to the intensive care unit.

The study included  90 patients with community acquired pneumonia admitted to the ICU or step-down unit of a university hospital during a 4-year period. All cases were evaluated prospectively except when they were on long term non steroidal antiinflammatory drugs or steroids .

36% were found to have been administered NSAIDs before they were referred to hospital. This group of patients were younger and had fewer comorbidities as compared to the group who were not given any NSAIDs. 

The group who received NSAIDs was found to have similar severity of disease at presentation, despite a longer duration of symptoms before referral.

Moreover, this group was seen to develop more pleuropulmonary complications, such as pleural empyema and lung cavitation. 37.5% had the complications as compared to 7% in patients who did not receive NSAIDs.

These patients had a higher frequency of pleural empyema (25%  as compared to 5%) and bacteremia (69% as compared to  27%).

Using multivariate analyses, NSAID exposure was independently associated with the occurrence of pleuropulmonary complications.

The authors concluded that exposure to non steroidal antiinflammatory drugs at  early stage of community acquired pneumonia is associated with a more complicated course but a blunted systemic response, which may be associated with a delayed diagnosis and a protracted course.

CHEST February 2011 vol. 139 no. 2 387-394

A study published in journal Molecular Psychiatry has reported that, mitochondrial dysfunction  is more common in children with autism and autism spectrum disorder.

In this study, evidence from published research was collated after performing comprehensive search. Eighteen publications representing a total of 112 children with autism spectrum disorder and mitochondrial dysfunction were identified.  There were two main objectives defined for the study

• To identify features of mitochondrial dysfunction in the general population of children with autism spectrum disorder.
• To identify characteristics of mitochondrial dysfunction in children with ASD and concomitant mitochondrial disease

Also included was the comparison of published literature of autism spectrum disorder children without mitochondrial dysfunction and, and non-autism spectrum disorder children with mitochondrial dysfunction .

The authors found that the prevalence of mitochondrial dysfuntion in population of autism spectrum disorder was 5.0%  which was very high as compared to  that  found in the general population.

Many mitochondrial biomarkers  like lactate, pyruvate, carnitine and ubiquinone were significantly different between autism spectrum disorder group and controls suggesting that  children with autism spectrum disorder have a spectrum of mitochondrial dysfunction of differing severity.

Following things were found more in autism spectrum disorder with mitochondrial dysfunction

• Seizures
• Motor delay
• Gastrointestinal abnormalities
• Female gender
• Elevated lactate and pyruvate

Most of the  autism spectrum disorders with mitochondrial dysfunction were not associated with genetic abnormalities thus raising the possibility of secondary mitochondrial dysfunction.

The authors concluded that the available  evidence supports the notion that mitochondrial dysfunction is associated with autism spectrum disorder. However, they recommended need for additional studies  to further define the role of mitochondrial dysfunction in autism spectrum disorder.

Molecular Psychiatry advance online publication 25 January 2011; doi: 10.1038/mp.2010.136