The effect of CagA status on response to Helicobacter pylori eradication therapy in Western Turkey

If cytotoxin-associated gene A (CagA) status affects the response rates of therapy, then it may be possible to predict Helicobacter pylori eradication rates. We aimed to evaluate the response to eradication treatment of H. pylori infection in CagA-positive and CagA-negative patients. A total of 184 patients (93 males, 91 females, mean age 42.6 ± 12.8 years) with H. pylori-positive chronic gastritis were studied. Subjects underwent a gastroscopy and biopsy specimens were taken from the gastric antrum, body, and fundus. Before the eradication therapy was given all patients were tested for CagA, TNF-alpha and gastrin levels. They were then prescribed lansoprazole (30 mg bid), clarithromycin (500 mg bid), and amoxicillin (1.0 mg bid) for one week. On the 8th week a second endoscopy was performed and further biopsy specimens were obtained from the same sites as in the initial endoscopy. One hundred and twenty-seven patients (69.1%) were found to be CagA positive and 57 patients (30.9%) were CagA negative. The total eradication rate was 82.6%. In the CagA-positive group this rate was 87.4%, and in the CagA-negative group it was 71.9% (P = 0.019). TNF-alpha levels were higher in the CagA-positive than in the CagA-negative group (P = 0.001). However, gastrin levels were not different between groups (P = 0.421). Our findings revealed that CagA-negative status might be a risk factor for failure of H. pylori triple therapies. The CagA pathogenicity island gives a growth advantage to H. pylori strains and has been associated with an increase in the inflammatory response at the gastric mucosal level. These properties could make CagA-positive H. pylori strains more susceptible to antibiotics.

Factors associated with adherence to antiretroviral therapy in HIV/AIDS patients: a cross-sectional study in Southern Brazil

A cross-sectional study was conducted on HIV-infected adults being treated with antiretroviral drugs at a reference service in Southern Brazil. Participants answered a sociodemographic questionnaire and were tested by scales assessing sociocognitive variables. Adherence to treatment was assessed by a self-report inventory developed for the study. Clinical information was obtained from the patients' records. Significance tests were conducted using univariate logistic regressions followed by multivariate logistic regression analysis. A total of 195 patients participated in the study and 56.9% of them reported > or = 95% adherence on the previous two days. In univariate analysis, the odds of adherence increased with self-efficacy (a person's conviction that he/she can successfully execute the behavior required to produce a certain desired outcome) in taking medications as prescribed (OR = 3.50, 95% CI 1.90-6.55), and decreased with perception of negative affect and physical concerns (OR = 0.71, 95% CI 0.53-0.95). The odds were lower for taking antiretroviral medications >4 times a day (OR = 0.44, 95% CI 0.20-0.94) and higher for patients with 8 years of schooling (OR = 2.28, 95% CI 1.12-4.66). In the multivariate analysis, self-efficacy (OR = 3.33, 95% CI 1.69-6.56) and taking medication >4 times a day (OR = 0.34, 95% CI 0.14-0.80) were independently associated with adherence. Self-efficacy was the most important predictor of adherence, followed by number of times antiretroviral medication was taken per day. Among sociodemographic and clinical variables, only the number of years of schooling was associated with adherence. Motivational interventions based on self-efficacy may be useful for increasing treatment adherence.

Dietary fiber, energy intake and nutritional status during the treatment of children with chronic constipation

The present prospective study was carried out to determine dietary fiber and energy intake and nutritional status of children during the treatment of chronic constipation. Twenty-five patients aged 2 to 12 years with chronic constipation were submitted to clinical evaluation, assessment of dietary patterns, and anthropometry before and after 45 and 90 days of treatment. The treatment of chronic constipation included rectal disimpaction, ingestion of mineral oil and diet therapy. The standardized diet prescribed consisted of regular food without a fiber supplement and met the nutrient requirements according to the recommended daily allowance. The fiber content was 9.0 to 11.9 g for patients aged less than 6 years and 12.0 to 18.0 g for patients older than 6 years. Sixteen patients completed the 90-day follow-up and all presented clinical improvement. The anthropometric variables did not change, except midarm circumference and triceps skinfold thickness which were significantly increased. Statistically significant increases were also found in percent calorie intake adequacy in terms of recommended daily allowance (55.5 to 76.5% on day 45 and to 68.5% on day 90; P = 0.047). Percent adequacy of minimum recommended daily intake of dietary fiber (age + 5 g) increased during treatment (from 46.8 to 52.8% on day 45 and to 56.3% on day 90; P = 0.009). Food and dietary fiber intake and triceps skinfold thickness increased during follow-up. We conclude that the therapeutic program provided a good clinical outcome.

Determinants of Bone Strength and Predictors of Hip Fracture among Finnish Adults. Results from the Health 2000 Survey and the Mini-Finland Health Survey

The objective of this thesis was to identify the determinants of bone strength and predictors of hip fracture in representative samples of Finnish adults. A secondary objective was to construct a simple multifactorial model for hip fracture prediction over a 10-year follow-up period. The study was based on the Health 2000 Survey conducted during 2000 to 2001 (men and women aged 30 years or over, n=6 035) and the Mini-Finland Health Survey conducted during 1978 to 1980 (women aged 45 years or over, n=2 039). Study subjects participated in health interviews and comprehensive health examination. In the Health 2000 Survey, bone strength was assessed by means of calcaneal quantitative ultrasound (QUS). The follow-up information about hip fractures was drawn from the National Hospital Discharge Register. In this study, age, weight, height, serum 25-hydroxyvitamin D (S-25(OH)D), physical activity, smoking and alcohol consumption as well as menopause and eventual HRT in women were found to be associated with calcaneal broadband ultrasound attenuation (BUA) and speed of sound (SOS). Parity was associated with a decreased risk of hip fracture in postmenopausal women. Age, height, weight or waist circumference, quantitative ultrasound index (QUI), S-25(OH)D and fall-related factors, such as maximal walking speed, Parkinson’s disease, and the number of prescribed CNS active medication were significant independent predictors of hip fracture. At the population level, the incremental value of QUS appeared to be minor in hip fracture prediction when the fall-related risk factors were taken into account. A simple multifactorial model for hip fracture prediction presented in this study was based on readily available factors (age, gender, height, waist circumference, and fallrelated factors). Prospective studies are needed to test this model in patient-based study populations.

Persistent organic pollutants in sediments and fish from Lake Victoria, Uganda

This thesis describes the occurrence and sources of selected persistent organic pollutants (POPs) such as polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs), polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs) and hexachlorocyclohexanes (HCHs) in the northern watershed of Lake Victoria. Sediments and fish were collected from three highly polluted embayments (i.e. Murchison Bay, Napoleon Gulf and Thurston Bay) of the lake. The analysis for PCDD/Fs, PCBs and PBDEs was done using a high resolution mass spectrometer coupled to a gas chromatograph (GC), and a GC equipped with an electron capture detector was used for HCHs. Total (Σ) PCDD/Fs, PCBs and PBDEs in sediments ranged from 3.19 to 478, 313 to 4325 and 60.8 to 179 pg g-1 dry weight (dw), respectively. The highest concentrations of pollutants were found at sites close to industrial areas and wastewater discharge points. The maximum concentrations of PCDD/Fs, PCBs, PBDEs and HCHs in fish muscle homogenates were 49, 779, 495 and 45,900 pg g-1 wet weight (ww), respectively. The concentrations of the pollutants in Nile perch (Lates niloticus) were significantly greater than those in Nile tilapia (Oreochromis niloticus), possibly due to differences in trophic level and dietary feeding habits among fish species. World Health Organization-toxic equivalency quotient (WHO2005-TEQ) values in the sediments were up to 4.24 pg g-1 dw for PCDD/Fs and 0.55 pg TEQ g-1 dw for the 12 dioxin-like PCBs (dl-PCBs). 23.1% of the samples from the Napoleon Gulf were above the interim sediment quality guideline value of 0.85 pg WHO-TEQ g-1 dw set by the Canadian Council for Ministers of the Environment. The WHO2005-TEQs in fish were 0.001-0.16 pg g-1 for PCDD/Fs and 0.001-0.31 pg g-1 ww for dl- PCBs. The TEQ values were within a permissible level of 3.5 pg g−1 ww recommended by the European Commission. Based on the Commission set TEQs and minimum risk level criteria formulated by the Agency for Toxic Substances and Disease Registry, the consumption of fish from Lake Victoria gives no indication of health risks associated to PCDD/Fs and PCBs. Principal component analysis (PCA) indicated that anthropogenic activities such as agricultural straw open burning, medical waste incinerators and municipal solid waste combustors were the major sources of PCDD/Fs in the watershed of Lake Victoria. The ratios of α-/γ-HCH varied from 0.89 to 1.68 suggesting that the highest HCH residues mainly came from earlier usage and fresh γ-HCH (lindane). In the present study, the concentration of POPs in fish were not significantly related to those in sediments, and the biota sediment accumulation factor (BSAF) concept was found to be a poor predictor of the bioavailability and bioaccumulation of environmental pollutants.

Twenty-four-hour esophageal pH monitoring in children and adolescents with chronic and/or recurrent rhinosinusitis

Gastroesophageal reflux (GER) disorder was studied in children and adolescents with chronic and/or recurrent rhinosinusitis not associated with bronchial asthma. Ten children with a clinical and radiological diagnosis of chronic and/or recurrent rhinosinusitis, consecutively attended at the Pediatric Otolaryngology Outpatient Clinic, Federal University of São Paulo, were evaluated. Prolonged esophageal pH monitoring was used to investigate GER disorder. The mean age of the ten patients evaluated (eight males) was 7.4 ± 2.4 years. Two patients presented vomiting as a clinical manifestation and one patient presented retrosternal pain with a burning sensation. Twenty-four-hour esophageal pH monitoring was performed using the Sandhill apparatus. An antimony probe electrode was placed in the lower third of the esophagus, confirmed by fluoroscopy and later by a chest X-ray. The parameters analyzed by esophageal pH monitoring included: total percent time of the presence of acid esophageal pH, i.e., pH below 4 (<4.2%); total number of acid episodes (<50 episodes); number of reflux episodes longer than 5 min (3 or less), and duration of the longest reflux episode (<9.2 min). One patient (1/10, 10%) presented a 24-h esophageal pH profile compatible with GER disorder. This data suggest that an association between chronic rhinosinusitis not associated with bronchial asthma and GER disorder may exist in children and adolescents, especially in those with compatible GER disorder symptoms. In these cases, 24-h esophageal pH monitoring should be performed before indicating surgery, since the present data suggest that 10% of chronic rhinosinusitis surgeries can be eliminated.

Effects of type of physical exercise and leisure activities on the depression scores of obese Brazilian adolescent girls

Several studies have indicated that depressive states may lead to hypokinesia with diminished metabolic rate and energy use. Hypokinesia associated with certain eating behaviors may lead to an unfavorable energy balance that can contribute to the emergence and prevalence of obesity among children and adults. The purpose of the present study was to examine the possibility of reducing depression inventory scores in female adolescents with third-degree obesity while testing the effectiveness of different exercise programs in reducing anxiety and depression scores. The sample consisted of 40 female subjects (mean age 16 ± 1.56 years) divided into 4 groups (aerobic training, anaerobic training, leisure activities, and control). Subjects had a body mass index of 95% or more in relation to the 50th percentile. The aerobic program consisted of three ergometric bicycle sessions per week over a 3-month period (12 weeks) and the activities were prescribed after determining the anaerobic ventilatory threshold (VO2 threshold). Anaerobic training was based on the Wingate anaerobic power test. The leisure program consisted of a varied range of activities (games, exercises, etc.). A nutritionist interviewed the members of these two groups and the control group every week in order to adapt them to the nutritional guidelines proposed for the study. The study showed that all three programs (aerobic exercise, anaerobic exercise and leisure activities) were effective in reducing body mass. However, we found a significant reduction when analyzing the depression scores only for aerobic exercise (18.9 ± 9.33 to 10.6 ± 9.56 or 43.9%) but no significant alterations for anaerobic exercise (11.36 ± 5.23 to 9.63 ± 4.78 or 15.22%) and leisure (17.28 ± 7.55 to 15.07 ± 7.54 or 12.78%), thus indicating that in principle this type of activity could be included to improve emotional well-being of obese adolescent girls.

Towards sustainable transport: A comparison of demographic and behavioural characteristics of Finnish and international car sharing users

SStrong evidence suggests that the climate is changing and that these changes are largely caused by human activities. A consensus exists among researchers that human activity is causing global warming and that actions to mitigate global warming need to be taken swiftly. The transportation sector, which relies heavily on fossil fuel burning and primarily oil, is one of the big contributors to air pollution problems at local, regional and global levels. It is the fastest growing source of greenhouse gas emissions and is estimated to be responsible for nearly a quarter of global energyrelated carbon dioxide emissions. Car sharing is a mobility solution encouraging its users to decrease private car usage in favour of communal transit and environmental goals. The idea of car sharing originates from the aspiration to decrease personal car ownership and to reduce vehicle distance travelled. This thesis seeks to complement the understanding of Finnish car sharing users and their usage through better categorization. Through better categorization and segmentation of Finnish car sharing users the thesis seeks to provide information for improved marketing insight. Research is done on the demographic and behavioural characteristics of Finnish car sharing users and they are compared with international findings about the characteristics of International car sharing users. The main research problem is Are Finnish car sharing users similar to international ones? A theoretical research framework on the determinants of individual car sharing usage is built based on international research about demographic and behaviouristic characteristics. After this a quantitative survey is performed to the customers of a Finnish car sharing organization. The data analysed in the thesis consist out of 532 answers received from the car sharing organizations customers. The data is analysed with descriptive and other exploratory methods, which create an understanding of Finnish car sharing users. At the end of the analysis the demographic and behavioural characteristics of Finnish car sharing users are compared with international ones. The research findings of the thesis indicate that the demographic and behavioural characteristics of Finnish car sharing usage largely follow those of their international counterparts. Thanks to the thesis results the car sharing organization is able to better target their customers through improved marketing insight.

Biomassan käsittely voimalaitoksissa

Tässä diplomityössä tutkitaan biomassan esikäsittelyä suurissa voimalaitoksissa. Työssä keskitytään puusta saataviin polttoaineisiin. Biomassan esikäsittely on tärkeä osa voimalaitoksen toimintaa. Sillä pyritään saamaan puulle halutut ominaisuudet loppukäyttöä, kuten polttoa tai kaasutusta varten. Puubiomassan tärkeimpiä ominaisuuksia ovat kosteus, palakoko ja tasalaatuisuus. Työ on jaettu neljään osaan. Ensimmäisessä osassa tutkitaan kiinteän biomassan ominaisuuksia ja ongelmia. Toisessa osassa esitellään erilaisia voimalaitoksissa käytettäviä puubiomassoja ja niiden erityisominaisuuksia ja -vaatimuksia. Kolmannessa osassa esitellään biomassan käsittelyä voimalaitoksella. Käsittely jaotellaan vastaanottoon, esikäsittelyyn, varastointiin ja käsittelylaitteistoihin. Kolmannessa osassa tutkitaan myös käsittelyn erityisvaatimuksia ja esitellään esimerkkejä biomassan kokonaiskäsittelystä laitoksella. Työn neljäs osa paneutuu biomassan käsittelyn turvallisuus- ja ympäristöasioihin. Puubiomassan esikäsittely on suunniteltava käytettävien puulaatujen ja -määrien mukaan. Biomassan kosteuden ollessa korkea, on tutkittava onko kuivurien käyttö kannattavaa ja perusteltua. Jos voimalaitokselle tuleva puu on epätasalaatuista tai sisältää epäpuhtauksia, on käytettävä erilaisia puhdistus- ja murskainlaitteistoja. Biomassan käsittelyssä syntyy melua ja päästöjä. Ympäristö- ja terveyshaittojen ehkäisemiseksi käsittelylaitteistoihin on suunniteltava tarpeelliset suojat ja varojärjestelmät.

Leijukerroslämmönsiirtimien tukkeutuminen biovoimalaitoksessa

Leijukerroslämmönsiirtimien, eli hiekanpalautuspolvessa sijaitsevien tulistimien tukkeutuminen on ollut Kaukaan Voima Oy:n biovoimalaitoksen suunnittelemattomien seisokkien suurin syy vuodesta 2012 lähtien. Tulistimet tukkeutuvat kahdella tavalla. Nopeassa tukkeutumisessa tulistinkammion seinien kuonakerrostumat romahtavat yhtäkkiä tulistimen päälle tukkien sen. Tämä johtaa aina koko laitoksen alasajoon. Hitaassa tukkeutumisessa tulistinputkien pinnalle muodostuu vähitellen kerrostuma sekä tulistinputkien väliin jää suurempia kappaleita, jotka tukkivat tulistinta. Nopea tukkeutuminen johtuu tuhkassa olevien alkali-, eli kalium- ja natriumyhdisteiden synnyttämistä kerrostumista lämmönsiirrinkammion seinille. Hidas tukkeutuminen johtuu osittain myös alkaliyhdisteistä, mutta merkittävämpi aine tulistinputkien pinnalla olevassa kerrostumissa näyttää olevan kalsiumsulfaatti, joka tukkii tulistinta. Palavan aineen pääsy tulistinkammioon ilmanjakoasetuksista ja tulistinkammion rakenteesta johtuen aiheuttaa kerrostumien syntymisen. Kerrostumien syntymiseen johtavat syyt johtuvat monesta tekijästä ja yksiselitteistä aiheuttajaa on vaikea määritellä. Selvin yhteys on lietteen epätasaisessa poltossa ja turpeen käytössä. Nykyisillä lietteenkäsittelylaitteilla lietteen tasainen syöttö on vaikeaa ja se aiheuttaa ongelmia. Turpeen poltto biopolttoaineiden rinnalla pitää tulistimet puhtaampina. Muita todennäköisiä kerrostumia lisääviä syitä ovat puhtaan hiekan vähäinen syöttömäärä ja usean huonomman polttoaineen yhtäaikainen poltto.

Karboksyylihappojen kromatografinen fraktiointi

Suurin osa alifaattisista karboksyylihapoista tuotetaan nykyään synteettisesti, mutta öljyn hinnan nousu ja ekologisempi ajattelutapa on aiheuttanut kiinnostusta tuottaa näitä karboksyyli- ja hydroksihappoja jatkossa fermentoimalla tai sellun valmistuksen sivuvirtana syntyvästä mustalipeästä. Nykyään mustalipeä poltetaan sellaisenaan soodakattiloissa keittokemikaalien regeneroimiseksi, energiaksi ja sähköksi. Jatkossa mustalipeästä voisi erottaa arvokkaat orgaaniset hapot ennen polttamista. Saadusta happoseoksesta tulisi erottaa yksittäiset alifaattiset karboksyylihapot toisistaan jatkojalostusta varten. Tämän kandidaatintyön tavoitteena oli selvittää, millä kromatografisella erotusmenetelmällä fermentointituotteina ja teollisuuden sivuvirtoina syntyvistä karboksyylihapposeoksista saadaan yksittäiset alifaattiset karboksyylihapot erotettua toisistaan. Mittaukset suoritettiin kolonnilla, jossa hartsipedin halkaisija oli 1,5 cm ja korkeus 15 cm. Kolonnin erototusmateriaaleina kokeiltiin vahvoja ja heikkoja kationinvaihtohartseja, vahvaa anioninvaihtohartsia ja polymeerisiä adsorbentteja. Erotettavaksi happoseokseksi valittiin sitruuna-, viini-, glykoli-, maito- ja etikkahapon seos. Tehokkain erotus saatiin Puroliten valmistamalla Macronet 270:lla, joka on mikrohuokoinen polymeerinen adsorbentti. Macronet 270:lla saatiin erotettua erityisesti viini- ja glykolihappo sitruuna-, maito- ja etikkahaposta. Yksittäisiä happoja ei saatu kuitenkaan kunnolla erotettua. Parhaat koeolosuhteet erotustehokkuuden ja retentioaikojen kannalta saatiin vesieluentin virtausnopeudella 2 mL/min, syöttöpulssin tilavuudella 5 mL ja kolonnin lämpötilassa 75 °C.

Direct costs of asthma in Brazil: a comparison between controlled and uncontrolled asthmatic patients

Asthma is a common chronic illness that imposes a heavy burden on all aspects of the patient's life, including personal and health care cost expenditures. To analyze the direct cost associated to uncontrolled asthma patients, a cross-sectional study was conducted to determine costs related to patients with uncontrolled and controlled asthma. Uncontrolled patient was defined by daytime symptoms more than twice a week or nocturnal symptoms during two consecutive nights or any limitations of activities, or need for relief rescue medication more than twice a week, and an ACQ score less than 2 points. A questionnaire about direct cost stratification in health services, including emergency room visits, hospitalization, ambulatory visits, and asthma medications prescribed, was applied. Ninety asthma patients were enrolled (45 uncontrolled/45 controlled). Uncontrolled asthmatics accounted for higher health care expenditures than controlled patients, US$125.45 and US$15.58, respectively [emergency room visits (US$39.15 vs US$2.70) and hospitalization (US$86.30 vs US$12.88)], per patient over 6 months. The costs with medications in the last month for patients with mild, moderate and severe asthma were US$1.60, 9.60, and 25.00 in the uncontrolled patients, respectively, and US$6.50, 19.00 and 49.00 in the controlled patients. In view of the small proportion of uncontrolled subjects receiving regular maintenance medication (22.2%) and their lack of resources, providing free medication for uncontrolled patients might be a cost-effective strategy for the public health system.

Palmupohjaisten raaka-aineiden soveltuvuus lämpökynttilämateriaaliksi

Työssä tutkittiin palmupohjaisten raaka-aineiden soveltuvuutta lämpökynttilän valmistukseen steariinin ja parafiinin kanssa. Palmupohjaiset raaka-aineet ovat halvempia kuin steariini ja parafiini, joten raaka-aineen korvaaminen palmupohjaisilla raaka-aineilla voisi tuoda säästöä kynttilänvalmistajalle. Lisäksi niillä voidaan vaikuttaa lämpökynttilän ominaisuuksiin. Teoriaosassa käsiteltiin lämpökynttilän raaka-aineista steariini, parafiini ja palmusteariini. Osassa selitettiin RAL-laatustandardin Quality Mark Candles vaatimukset lämpökynttilälle sekä valuastialle ja keskusteltiin valulämpötilan, jäähdytyksen, viskositeetin ja haaroittuneiden yhdisteiden lukumäärän vaikutuksesta lämpökynttilän koostumukseen. Kokeellisessa osassa valmistettiin lämpökynttilöitä steariinin ja palmupohjaisten raaka-aineiden seoksista palmuraaka-aineiden määrillä 10, 20 ja 30 m- %:a. Parafiinin ja palmusteariinin sekä palmun mid-fraktion seokset valmistettiin palmuraaka-aineiden osuuksilla 10, 20, 40 ja 50 m- %:a ja myös palmusteariinin soft-fraktiolla kokeiltiin seosta 50 m- %:lla. Steariinin ja palmupohjaisten raaka-aineiden seokset eivät toimineet ainakaan käytetyillä sydänlangoilla. Liekinkorkeudet olivat alhaisia eivätkä visuaaliset vaatimukset täyttyneet. Parafiinin ja palmupohjaisten raaka-aineiden seoksista valmistetut kynttilät paloivat ideaalisesti palmuraaka-aineiden osuuksilla 35 – 50 m- %:a. Tulosten perusteella fraktion valinnalla ei näyttänyt olevan merkitystä, mutta palmusteariini on ominaisuuksiensa puolesta kynttilänvalmistukseen soveltuvin. Liekinkorkeus ja palovuo laskivat lineaarisesti palmuraaka-aineen osuuden kasvaessa parafiinikynttilässä.

Comparison of the effectiveness of initial combined antiretroviral therapy with nelfinavir or efavirenz at a university-based outpatient service in Brazil

Since there are some concerns about the effectiveness of highly active antiretroviral therapy in developing countries, we compared the initial combination antiretroviral therapy with zidovudine and lamivudine plus either nelfinavir or efavirenz at a university-based outpatient service in Brazil. This was a retrospective comparative cohort study carried out in a tertiary level hospital. A total of 194 patients receiving either nelfinavir or efavirenz were identified through our electronic database search, but only 126 patients met the inclusion criteria. Patients were included if they were older than 18 years old, naive for antiretroviral therapy, and had at least 1 follow-up visit after starting the antiretroviral regimen. Fifty-one of the included patients were receiving a nelfinavir-based regimen and 75 an efavirenz-based regimen as outpatients. Antiretroviral therapy was prescribed to all patients according to current guidelines. By intention-to-treat (missing/switch = failure), after a 12-month period, 65% of the patients in the efavirenz group reached a viral load <400 copies/mL compared to 41% of the patients in the nelfinavir group (P = 0.01). The mean CD4 cell count increase after a 12-month period was also greater in the efavirenz group (195 x 10(6) cells/L) than in the nelfinavir group (119 x 10(6) cells/L; P = 0.002). The efavirenz-based regimen was superior compared to the nelfinavir-based regimen. The low response rate in the nelfinavir group might be partially explained by the difficulty of using a regimen requiring a higher patient compliance (12 vs 3 pills a day) in a developing country.

Exercise may cause myocardial ischemia at the anaerobic threshold in cardiac rehabilitation programs

Myocardial ischemia may occur during an exercise session in cardiac rehabilitation programs. However, it has not been established whether it is elicited when exercise prescription is based on heart rate corresponding to the anaerobic threshold as measured by cardiopulmonary exercise testing. Our objective was to determine the incidence of myocardial ischemia in cardiac rehabilitation programs according to myocardial perfusion SPECT in exercise programs based on the anaerobic threshold. Thirty-nine patients (35 men and 4 women) diagnosed with coronary artery disease by coronary angiography and stress technetium-99m-sestamibi gated SPECT associated with a baseline cardiopulmonary exercise test were assessed. Ages ranged from 45 to 75 years. A second cardiopulmonary exercise test determined training intensity at the anaerobic threshold. Repeat gated-SPECT was obtained after a third cardiopulmonary exercise test at the prescribed workload and heart rate. Myocardial perfusion images were analyzed using a score system of 6.4 at rest, 13.9 at peak stress, and 10.7 during the prescribed exercise (P < 0.05). The presence of myocardial ischemia during exercise was defined as a difference ≥2 between the summed stress score and summed rest score. Accordingly, 25 (64%) patients were classified as ischemic and 14 (36%) as nonischemic. MIBI-SPECT showed myocardial ischemia during exercise within the anaerobic threshold. The 64% prevalence of ischemia observed in the study should not be looked on as representative of the whole population of patients undergoing exercise programs. Changes in patient care and exercise programs were implemented as a result of our finding of ischemia during the prescribed exercise.