RESUMO
A follow-up study was performed to analyze the effects of hepatitis C virus (HCV) infection on morbidity and mortality in the adult population from a village in Japan found to have endemic levels of both HCV and human T lymphotropic virus type I (HTLV-I). By use of the Cox proportional hazards model, rate ratios (RRs) and 95% confidence intervals (CIs) were estimated. Strong, significant effects of seropositivity for antibodies to HCV on self-reported incident liver disease (RR, 3.5; 95% CI, 1.9-6.4) and on death due to liver cancer (RR, 8.2; 95% CI, 1.6-41.4) were observed. Dual infection with HCV and HTLV-I seemed to have a synergistic effect on incident liver disease (RR, 5.9) as well as on death from liver cancer (RR, 21.9). HCV infection also was positively, although not significantly, associated with reported incident diabetes. Our findings suggest that coinfection with HTLV-I may affect the course of HCV-associated disease.
Assuntos
Infecções por HTLV-I/epidemiologia , Hepatite C/epidemiologia , Neoplasias Hepáticas/epidemiologia , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Infecções por HTLV-I/complicações , Infecções por HTLV-I/mortalidade , Hepatite C/complicações , Hepatite C/mortalidade , Humanos , Japão/epidemiologia , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
OBJECTIVE: The purpose of this study was to determine the prevalence of upper gastrointestinal tract lesions in children with human immunodeficiency virus (HIV) infection who undergo endoscopy of the upper gastrointestinal tract and to identify important clinical predictors of abnormal endoscopic results. METHODS: All HIV-infected children who underwent endoscopy and were followed at Children's Hospital, Boston, from January 1985 to August 1994 were studied. The main outcome measure was endoscopic results, which were categorized into observational, histologic, and microbiologic findings. Potential predictors included height, weight, nutritional interventions, HIV disease stage, CD4 T-lymphocyte count, medications, active infections, and indications for endoscopy. RESULTS: Forty-three endoscopies in unique patients are reported. Most children had advanced HIV infection (67% acquired immunodeficiency syndrome, mean CD4 T-lymphocyte count z score = -2.71, weight z score = -2.04). An abnormal endoscopic finding was discovered in 93% of children and confirmed by histologic, microbiologic, or a combination of these studies in 72% of children. Thirty-five percent of children had an opportunistic pathogen identified endoscopically; 65% of these pathogens were previously undiagnosed. Observational findings often were poor indicators of histologic and microbiologic abnormalities. Independent predictors of abnormal histologic findings include younger age at endoscopy (odds ratio (OR) = 1.16 per year, 95% confidence interval (CI) (1.02, 1.33)) and guaiac-negative stools (OR = 16.7, 95% CI (1.92, 142.9)). Independent predictors of finding a pathogen at the time of endoscopy include a greater number of indications for endoscopy (OR = 2.6 per indication, 95% CI (1.3, 5.3)) and diagnosis of acquired immunodeficiency syndrome (OR = 16.4, 95% CI (1.3, 213)). No other gastrointestinal, nutritional, or immunologic parameters were significantly predictive of endoscopic outcomes. Medical management was changed in 70% of children because of the endoscopic findings. CONCLUSIONS: Endoscopy is a useful tool to direct therapy against peptic and infectious disorders of the upper gastrointestinal tract in children with HIV infection. Specific gastrointestinal symptoms are not useful predictors of abnormal results.
Assuntos
Endoscopia Gastrointestinal , Gastroenteropatias/etiologia , Infecções por HIV/complicações , Infecções Bacterianas/diagnóstico , Infecções Bacterianas/etiologia , Boston , Criança , Pré-Escolar , Duodenopatias/diagnóstico , Duodenopatias/etiologia , Duodenopatias/microbiologia , Doenças do Esôfago/diagnóstico , Doenças do Esôfago/etiologia , Doenças do Esôfago/microbiologia , Feminino , Gastroenteropatias/diagnóstico , Gastroenteropatias/epidemiologia , Humanos , Lactente , Masculino , Análise Multivariada , Estado Nutricional , Valor Preditivo dos Testes , Prevalência , Estudos Retrospectivos , Gastropatias/diagnóstico , Gastropatias/etiologia , Gastropatias/microbiologiaRESUMO
Left ventricular fractional shortening (FS) is dependent on left ventricular preload and afterload, as well as contractility. Contractility may therefore not be accurately described by FS, especially in infants and children infected with human immunodeficiency virus (HIV), who tend to have abnormal left ventricular preload and afterload. We therefore examined the magnitude and clinical impact of the discrepancy between FS and contractility by assessment of 177 echocardiograms from 76 HIV-infected pediatric patients (median age, 1.9 years). The studies included simultaneous measurements of left ventricular FS, contractility, preload, and afterload. The correlation between contractility and FS was modest (r = 0.70; p < 0.001), and was weaker in children less than 2 years of age (r = 0.52) than in older children (r = 0.84). FS incorrectly predicted contractility in 46% of the studies; 43% with depressed FS (< 28%) had either normal (17/42) or enhanced (1/42) contractility. For 67% of echocardiograms, FS and contractility differed by > 1 SD, and for 36% the difference was > 2 SD. These differences remained after adjustment of FS for age or body surface area. Afterload was abnormal in 42% and preload in 21% of all echocardiograms. High preload predicted that FS would overestimate contractility (p = 0.002); high afterload predicted that FS would underestimate contractility (p < 0.001). The discrepancy between FS and contractility was larger among children who were younger, had more advanced HIV disease, or were not sedated during echocardiography. One third of children with congestive symptoms had normal contractility and depressed FS; the discrepancy was primarily due to loading conditions. We conclude that the high incidence of abnormal loading conditions in HIV-infected infants and children limits the usefulness of load-dependent FS for assessing contractility. Measurements of loading conditions and load-independent indexes, which more directly reflect contractility, allow a more accurate determination of myocardial status and may lead to better clinical management.
Assuntos
Infecções por HIV/fisiopatologia , Contração Miocárdica , Função Ventricular Esquerda , Síndrome da Imunodeficiência Adquirida/fisiopatologia , Adolescente , Adulto , Criança , Pré-Escolar , Eletrocardiografia , Ventrículos do Coração/fisiopatologia , Humanos , Lactente , Sensibilidade e EspecificidadeRESUMO
Because pancreatitis has been reported frequently in adults with human immunodeficiency virus infection, we sought to determine the incidence of pancreatitis in children with acquired immunodeficiency syndrome by reviewing all records of children with AIDS, their serum amylase and lipase levels, and the factors associated with pancreatitis through a case-control analysis. During a 6-year period pancreatitis developed in 9 (17%) of 53 pediatric patients with AIDS. Six children had vertical transmission of infection and three patients had acquired HIV infection through contaminated blood products. Pancreatitis developed at a median age of 5.2 years (range 1.2 to 20 years). All patients had vomiting and abdominal pain. When the patients were first seen, lipase values were elevated more than amylase values (p = 0.028). Amylase and lipase levels declined at comparable rates. In the case-control analysis, pentamidine isethionate was significantly associated with pancreatitis (p = 0.02); the risk was greater in patients who received pentamidine isethionate and had absolute CD4 T-lymphocyte counts less than 100 cells/mm3 (p = 0.001). Infections associated with the onset of pancreatitis included cytomegalovirus (4), Cryptosporidium (1), Pneumocystis carinii pneumonia (3), and Mycobacterium avium intracellulare (1). Coinfection with cytomegalovirus was associated with a protracted course in four children. Ultrasonographic examination demonstrated biliary ductal dilatation 6 months after the onset of pancreatitis in one child. Seven children have died at a mean of 8 months after the initial onset of pancreatitis; the one living child has survived 5 months from the onset of pancreatitis. We conclude that pancreatitis is common in pediatric patients with AIDS and may be related to pentamidine isethionate exposure, especially when absolute CD4 T-lymphocyte counts are less than 100 cells/mm3. Serum amylase levels do not always accurately predict the onset of pancreatitis; serum lipase levels should be measured in children with symptoms. The onset of pancreatitis in an HIV-infected child is a poor prognostic indicator.
Assuntos
Síndrome da Imunodeficiência Adquirida/complicações , Pancreatite/complicações , Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Síndrome da Imunodeficiência Adquirida/imunologia , Adolescente , Adulto , Amilases/sangue , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Lipase/sangue , Masculino , Infecções Oportunistas/complicações , Pancreatite/enzimologia , Subpopulações de Linfócitos TRESUMO
This study utilized a historical cohort to examine the relationship between maternal cocaine use during pregnancy and the occurrence of congenital cardiovascular abnormalities. All neonatal drug screens performed at Boston City Hospital during an 18-month period were reviewed (n = 554); for 214 (39%) screened high-risk neonates, results of toxicologic screens were positive for cocaine, and 340 (61%) neonates had no detectable cocaine. We compared the occurrence of cardiovascular malformations and electrocardiographic abnormalities in these two groups. Matches were sought between these 554 infants and our pediatric cardiology data base, which consisted of inpatient consultation, outpatient consultation, and electrocardiography. Forty-nine patients had drug screens and were also entered into our cardiology data base: 25 had both consultations and electrocardiograms, and 24 had electrocardiograms only. The rate of cardiac anomalies among the cocaine-positive infants was significantly higher (relative risk = 3.7; 95% confidence interval: (1.4, 9.4)) than the rate of these anomalies among the cocaine-negative comparison group (65/100 vs 18/1000); the rate for cocaine-positive infants was also significantly higher than published rates for general populations of infants. Several electrocardiographic abnormalities, high-grade ventricular ectopy, and cardiorespiratory arrests were also noted in our study population. We conclude that cocaine exposure during prenatal life appears to predispose infants to structural cardiovascular malformations, electrocardiographic abnormalities, and, possibly, cardiopulmonary autonomic dysfunction.