Objective To describe the prevalence and factors associated with nonalcoholic fatty liver disease (NAFLD) among HIV-infected persons not infected with hepatitis C virus (HCV). Design A cross-sectional study among HIV-infected patients in a large HIV clinic. Methods NAFLD was defined as steatosis among patients without viral hepatitis (B or C) co-infection or excessive alcohol use. The prevalence of NAFLD was identified by ultrasound examination evaluated by two radiologists blinded to the clinic information; liver biopsies were performed on a subset of the study population. Factors associated with NAFLD evaluated by proportional odds logistic regression models. Results Sixty-seven (31%) of 216 patients had NAFLD based on ultrasound evaluation. Among those with NAFLD, steatosis was graded as mild in 60%, moderate in 28%, and severe/ marked in 12%. Factors associated with the degree of steatosis on ultrasound examination in the multivariate model included increased waist circumference (odds ratio [OR] 2.1 per 10 cm, p<0.001), elevated triglycerides (OR= 1.2 per 100 mg/dl, p=0.03), and lower HDL levels (OR 0.7, p=0.03). African Americans were less likely to have NAFLD compared to Caucasians (14% vs. 35%), although this did not reach statistical significance (OR= 0.4, p=0.08). Similar associations were noted for the subset of patients diagnosed by liver biopsy. CD4 cell count, HIV viral load, duration of HIV infection, and antiretroviral medications were not independent risk factors associated with NAFLD after adjustment for dyslipidemia or waist circumference. Conclusion NAFLD was common among this cohort of HIV-infected, HCV-seronegative patients. NAFLD was associated with a greater waist circumference, low HDL and high triglyceride levels. Antiretroviral medications were not associated with NAFLD; prospective studies are needed to confirm this finding.

Erectile dysfunction (ED) and hypogonadism are increasingly recognized conditions, however, the prevalence and etiologies of these conditions among HIV-infected men remain unclear. We studied 300 HIV-infected men who completed standardized questionnaires regarding sexual function and hypogonadal symptoms. An early morning testosterone test was performed; patients with a low serum testosterone level (defined by <300 ng/dL), underwent additional blood tests to determine the etiology of the hypogonadism. The participants' mean age was 39 years (range, 19-72); 61% were Caucasian; 24%, African American; 9%, Hispanic; and 5% other. Participants had been HIV-positive for a mean of 9 years (range, 0.5-20) with a mean CD4 count of 522 cells/mm(3) (range, 1-1531). Sixty percent were receiving antiretroviral therapy. ED was reported by 61.4%; of those with ED, 32% did not have a rigid enough erection for penetration, and 46% were unable to sustain an erection for the completion of intercourse. In the multivariate analysis, increasing age (odds ratio [OR] 1.4 for a 5-year increment, p < 0.001) and depression (OR 2.64, p < 0.0001) were associated with ED. A higher current CD4 count was protective (OR 0.80 for each 100 cells/mm(3), p = 0.004). Only 25% of patients with ED had utilized a phosphodiesterase-5-inhibitor for treatment. Seventeen percent of the 300 men were hypogonadal; there was no correlation between hypogonadism and ED. Increasing age and a higher body mass index (BMI) were positively associated with hypogonadism, while smoking was negatively associated (OR 0.44, p = 0.02). All patients with low testosterone had secondary hypogonadism. There was no association between ED or hypogonadism with the current, past, or cumulative use of HIV medications.

SummaryBackgroundInfluenza causes significant morbidity and mortality despite currently available treatments. Anecdotal reports suggest plasma with high antibody titers towards influenza may be of benefit in the treatment of severe influenza.MethodsWe conducted a randomized, open-label, multicenter phase 2 trial at 29 academic medical centers in the United States to assess the safety and efficacy of anti-influenza plasma with hemagglutination inhibition (HAI) antibody titers of ≥ 1:80 to the infecting strain. Hospitalized children and adults (including pregnant women) with severe influenza A or B (defined as hypoxia or tachypnea) were randomly assigned to receive either 2 units (or pediatric equivalent) of anti-influenza plasma plus standard care (P+S), versus standard care alone (S), and were followed for 28 days. The primary endpoint was time to normalization of patients’ respiratory status (respiratory rate of ≤ 20 for adults or age defined thresholds of 20–38 for children), and a room air saturation of oxygen ≥ 93%. ClinicalTrials.gov Identifier: NCT01052480FindingsBetween January 13, 2011 and March 2, 2015, 113 participants were screened, and 98 were randomized. Of the participants with confirmed influenza, 28 of 42 (67%) of P+S participants normalized their respiratory status by Day 28, as compared to 24 of 45 (53%) of S participants (p=0·069). The estimated hazard ratio comparing P+S to S was 1·71 (95% CI: 0·96 to 3·06). Six participants died, 1 (2%) and 5 (10%) from the P+S and S arms respectively (p=0·093). P+S participants had non-significant reductions in days in hospital (median 6 vs. 11 days, p=0·13) and days on mechanical ventilation (median 0 vs. 3 days, p=0·14), and significantly improved clinical status at Day 7 (p=0·020). Fewer P+S participants experienced SAEs compared to S recipients (20% vs. 38%, p= 0·041), the most frequent of which were acute respiratory distress syndrome (1 [2%] vs 2 [4%]) and stroke (1 [2%] vs 2 [4%]).InterpretationResults from this Phase II randomized trial of immune plasma for the treatment of severe influenza provides support for a possible benefit of immunotherapy across the primary and secondary endpoints. A Phase III randomized trial is now underway to further evaluate this intervention.

Venous thrombotic events (VTEs) may occur at higher rates among HIV patients; some studies suggest that HAART may increase the risk for these potentially life-threatening events. We performed a retrospective study among HIV patients to evaluate the incidence and risk factors for VTEs during the HAART era. A literature review was performed examining VTEs in the pre-and post HAART eras. Seventeen (3.7%) of 465 HIV patients experienced a VTE. The overall incidence rate of deep VTEs among HIV positive persons was 377 cases/100,000 person-years, a four-fold higher rate compared to age-matched males in the general population. The median age at VTE was 36 years (range 27-68). Patients with a thrombosis compared to those without had significantly lower current CD4 (153 vs. 520 cells/mm 3 , p<0.001) and nadir (76 vs. 276 cells/mm 3 , p<0.001) CD4 counts, higher viral loads (3.6 vs. 1.7 log 10 copies/ml, p=0.003), and more likely to have a diagnosis of AIDS (76% vs. 32%, p<0.001); there were no differences in demographics, hyperlipidemia, current use of HAART, the duration of HAART or PI exposure. A review of the literature noted 129 VTE cases; mean age was 40 years, mean CD4 count was 181 cells/mm 3 , the majority of patients were not receiving HAART, and the most common risk factor was an ongoing infection. Thrombotic events are occurring among HIV patients despite their relatively young ages. Advanced HIV disease is a risk factor for development of thromboses, possibly due to an increased inflammatory state or the presence of concurrent comorbidities such as infections. HAART or PI therapy does not appear to play a significant role in the occurrence of VTEs.

Hand infections are commonly seen by orthopedic surgeons as well as emergency room and primary care physicians. Identifying the cause of the infection and initiating prompt and appropriate medical or surgical treatment can prevent substantial morbidity. The most common bacteria implicated in hand infections remain Staphylococcus aureus and Streptococcus species. Methicillin-resistant S aureus infections have become prevalent and represent a difficult problem best treated with empiric antibiotic therapy until the organism can be confirmed. Other organisms can be involved in specific situations that will be reviewed. Types of infections include cellulitis, superficial abscesses, deep abscesses, septic arthritis, and osteomyelitis. In recent years, treatment of these infections has become challenging owing to increased virulence of some organisms and drug resistance. Treatment involves a combination of proper antimicrobial therapy, immobilization, edema control, and adequate surgical therapy. Best practice management requires use of appropriate diagnostic tools, understanding by the surgeon of the unique and complex anatomy of the hand, and proper antibiotic selection in consultation with infectious disease specialists.